[lab data]
2025-06-06 Anti-HBc Reactive
2025-06-06 Anti-HBc Value 6.04 S/CO
2025-06-06 HBsAg Nonreactive
2025-06-06 HBsAg Value 0.33 S/CO
2025-06-06 Anti-HCV Nonreactive
2025-06-06 Anti-HCV Value 0.21 S/CO
[exam finding]
2025-12-14 ECG
2025-10-22 Pathology - esophageal biopsy
2025-10-22 Miniprobe Endoscopic Ultrasound
2025-10-20 ECG
2025-09-04 CT - chest
2025-08-31 ECG
2025-08-26 ECG
2025-08-06 Sonography - abdomen
2025-07-25 CT - brain
2025-05-06 PD-L1 (28.8)
2025-04-30 ECG
2025-04-08 CT - chest
2025-04-07 Miniprobe Endoscopic Ultrasound
2025-04-01 Pathology - esophageal biopsy
2025-03-31 Esophagogastroduodenoscopy, EGD
2025-03-31 Sonography - abdomen
2025-02-19 ECG
2025-01-18 CT - chest
2024-12-31 ECG
2024-12-23 Pathology
2024-12-23 Pathology
2024-12-23 Miniprobe Endoscopic Ultrasound
2024-12-20 Sonography - abdomen
2024-11-26 CT - brain
2024-11-26 ECG
2024-11-18 Pathology - stomach biopsy
2024-11-18 Esophagogastroduodenoscopy, EGD
2024-10-13 ECG
2024-10-01 PET
2024-09-30 Surgical Pathology Level IV
2024-09-30 Miniprobe Endoscopy Ultrasound
2024-09-28 CT
2024-09-27 ECG
2024-09-21 CT - abdomen
2024-09-16 Pathology - esophageal biopsy
2024-09-16 Esophagogastroduodenoscopy, EGD
2024-09-16 Sonography - abdomen
2024-08-31 ECG
2024-08-23 ECG
2024-08-09 Surgical Pathology Level IV
2024-08-08 Upper GI Mucosal Resection
2024-08-06 ECG
2024-08-02 ECG
2024-06-24 Pathology - esophageal biopsy
2024-06-24 Esophagogastroduodenoscopy, EGD
2024-05-30 Sonography - abdomen
2024-05-09 CT - abdomen
2024-05-08 Esophagogastroduodenoscopy, EGD
2024-05-03 Pathology - esophageal biopsy
2024-05-02 Endoscopic radiofrequency ablation
2024-04-24 Sonography - abdomen
2024-03-18 Pathology - esophageal biopsy
2024-03-18 Pathology - esophageal biopsy
2024-03-18 Miniprobe Endoscopic Ultrasound
2024-01-30 Pathology - esophageal biopsy
2024-01-29 Endoscopic radiofrequency ablation
2023-12-25 Esophagogastroduodenoscopy, EGD
2023-12-22 Sonography - abdomen
2023-10-16 Miniprobe Endoscopic Ultrasound
2023-08-11 CT - brain
2023-07-07 CT - chest
2023-07-03 Miniprobe Endoscopic Ultrasound
2023-06-08 Pathology - stomach biopsy
2023-06-08 Pathology - stomach biopsy
2023-06-07 CT - abdomen
2023-06-07 Esophagogastroduodenoscopy, EGD
2023-05-02 EEG
2023-02-08 Sonography - abdomen
[MedRec]
2025-12-24 ~ 2025-12-28 Hemato-Oncology Yang MuJun
2025-11-26 ~ 2025-11-30 Hemato-Oncology Yang MuJun
2025-06-06 ~ 2025-06-10 Hemato-Oncology Yang MuJun
2025-04-30 ~ 2025-05-15 POMR Gong ZiXiang
[consultation]
2025-04-30 Hemato-Oncology
2025-04-09 Thoracic Surgery
2025-04-09 Radiation Oncology
2024-10-04 Radiation Oncology
2022-09-27 Cardiology
2021-03-25 Plastic and Reconstructive Surgery
2020-12-22 Chest Medicine
2020-06-10 Neurology
2020-01-05 Ear Nose Throat
[surgical operation]
2022-11-30
2018-12-20
2018-11-28
2018-11-08
2018-10-29
2018-09-18
2018-09-13
2018-05-29
2018-05-10
2018-03-29
2018-03-22
[radiotherapy]
[immunochemotherapy]
Key Insights/Summary
Problem 1. Decompensated alcoholic liver cirrhosis with portal hypertension and recurrent hepatic encephalopathy (Child B)
Problem 2. Esophageal squamous cell carcinoma, middle esophagus, treated with CCRT and ongoing immunochemotherapy; response/restaging uncertainty
Problem 3. Cytopenias (chronic thrombocytopenia with mild leukopenia) from hypersplenism and treatment effects; bleeding risk in portal hypertension
Problem 4. Electrolyte vulnerability (recurrent hypomagnesemia/hypokalemia) during cirrhosis and chemotherapy
Problem 5. Cardiovascular risk: abnormal ECG patterns and episodic hypertension; arrhythmia risk in cirrhosis/electrolyte instability
Problem 6. Aspiration-related bronchiolitis/pneumonitis risk and chronic pulmonary vulnerability
Problem 7. HBV reactivation risk (anti-HBc reactive) under immunotherapy; antiviral prophylaxis
Problem 8. Severe obesity (BMI 39.7) and metabolic risk impacting cardiopulmonary reserve and treatment tolerance
Key insights / summary
Problem 1. Esophageal squamous cell carcinoma, middle third, stage IIIB, post definitive CCRT, on nivolumab + PF2 (dose-modified) with mixed surveillance signals
Problem 2. Alcoholic liver cirrhosis with portal hypertension, splenomegaly, and esophageal/gastric varices (Child-Pugh B)
Problem 3. Hepatic encephalopathy risk with hyperammonemia
Problem 4. Hematologic toxicity and bleeding risk: thrombocytopenia and leukopenia in the setting of hypersplenism and chemotherapy
Problem 5. Electrolyte derangements: hypomagnesemia (and downstream arrhythmia risk)
Problem 6. Cardiac risk signals on ECG in a patient receiving fluoropyrimidine-based therapy
Problem 7. Aspiration-related bronchiolitis/pneumonitis risk in an esophageal cancer patient
Problem 8. Hepatitis B status and reactivation risk under immunochemotherapy
Problem 9. Gallbladder stone / lesion and chronic gastroduodenal ulcer disease in cirrhosis
Medication reconciliation highlights (current admission context, 2025-12-24 to 2025-12-26)
This is a middle-aged man with recurrent squamous cell carcinoma of the mid-esophagus (cT2N1Mx), previously treated with CCRT in 2024, now receiving immunochemotherapy with Nivolumab + PF2 (cisplatin/5-FU). Comorbidities include alcohol-related cirrhosis (Child B), thrombocytopenia, and prior hepatic encephalopathy. The second cycle of PF2 was administered on 2025-07-28 with cisplatin at 50% and 5-FU at 40% dose due to liver function concerns. Vital signs remain stable, with no febrile episodes. Labs show improving thrombocytopenia, controlled ammonia levels, and no signs of acute hepatic or renal injury. Tumor markers (CEA, SCC, CA199) are within normal limits as of 2025-07-08. No acute neurological events were detected on CT (2025-07-25). Overall, the patient is tolerating therapy with stable performance status (ECOG 1).
Problem 1. Recurrent esophageal squamous cell carcinoma (T2N1Mx)
Problem 2. Liver cirrhosis with hyperammonemia and portal hypertension
Problem 3. Thrombocytopenia (likely multifactorial: cirrhosis + chemotherapy)
Problem 4. Renal function under cisplatin (not posted)
Problem 5. Blood pressure monitoring and cardiovascular risk (not posted)
This 50-year-old man with a background of alcohol-related cirrhosis (Child B), hepatic encephalopathy, and prior hepatocellular carcinoma has recurrent esophageal squamous cell carcinoma (T2N1Mx) following CCRT in late 2024. He initiated second-line immunochemotherapy with Nivolumab + PF2 on 2025-06-06. He remains clinically stable with preserved ECOG 1, no overt hepatic encephalopathy, mild thrombocytopenia, and preserved renal and electrolyte profiles. Recent vital signs and labs (2025-07-01 and 2025-07-03) are stable.
Problem 1. Recurrent esophageal squamous cell carcinoma, stage T2N1Mx
Problem 2. Chronic liver cirrhosis with encephalopathy risk
Problem 3. Thrombocytopenia with risk of bleeding
Problem 4. Electrolyte and renal function under cisplatin-based chemotherapy (below not posted)
Problem 5. Blood pressure elevation and cardiovascular monitoring
This 50-year-old man with a history of alcohol-related cirrhosis (Child B), hepatic encephalopathy, and bilateral hepatocellular carcinoma (post-TACE and HAIC), was diagnosed with moderately differentiated squamous cell carcinoma of the middle third esophagus, stage cT2N2M0. He previously received CCRT (PF1) with radiotherapy from 2024-10-15 to 2024-11-22. Recurrent esophageal malignancy was pathologically confirmed (EGD 2025-03-31, biopsy 2025-04-01, EUS 2025-04-07), restaged as T2N1Mx, and not amenable to further surgery or radiotherapy. Current management includes immunochemotherapy with Nivolumab + PF2 (2025-06-06). He remains ECOG 1, afebrile, with stable vitals and lab parameters except for chronic thrombocytopenia and fluctuating hyperammonemia, now improved (157 → 69 µmol/L from 2025-06-06 to 2025-06-09). Liver function is relatively preserved.
Problem 1. Recurrent esophageal squamous cell carcinoma, stage cT2N1Mx
Problem 2. Chronic hepatic encephalopathy with cirrhosis (Child B)
Problem 3. Chronic thrombocytopenia
Problem 4. Renal function and electrolyte monitoring under chemotherapy
Problem 5. Nutritional and general performance status
[exam finding]
2025-11-20 CT - chest
2025-11-07, 2025-10-17 CXR
2025-09-25 Pathology - bone marrow biopsy
2025-09-25 2D transthoracic echocardiography
2025-09-24 ECG
2025-09-24 CXR
2025-09-19 CXR
2025-09-15 PET
2025-08-26 Pathology - lymph node biopsy
2025-08-25 ECG
2025-07-23 CT
2025-07-16 Sonography - soft tissue
2025-05-13 CT - brain
2024-04-17 Thyroid ultrasound
2024-04-17 Fundoscopy
2024-02-27 Papanicolaou test
2024-02-26 Sonography - gynecology
2023-11-15 MRI - pelvis
2023-10-26 Pathology - endometrium curettage/biopsy
2023-09-27 Pathology - endocervix curettage/biopsy
[MedRec]
2025-12-23 SOAP Nephrology Wu ZheXiong
2025-12-07 ~ 2025-12-10 POMR Hemato-Oncology Gao WeiYao
2025-11-26 SOAP Metabolism and Endocrinology Hu YaHui
2025-11-26, 2025-09-03 SOAP Cardiology Zhang HengJia
2025-10-14 SOAP Hemato-Oncology Gao WeiYao
2025-08-25 ~ 2025-08-27 POMR General and Gastroenterological Surgery Lai JieWen
2025-07-08 SOAP Nephrology Wu ZheXiong
[surgical operation]
2025-09-19
2025-08-26
2023-09-27
2019-05-31
[immunochemotherapy]
Key insights/summary
Problem 1. Diffuse large B-cell lymphoma, GCB subtype, Lugano stage III, on curative-intent chemoimmunotherapy
Problem 2. Cardiac risk management during anthracycline-containing therapy (liposomal doxorubicin substitution), with CAD history and diastolic dysfunction
Problem 3. Chronic kidney disease stage 3 with fluctuating renal function during chemotherapy
Problem 4. Electrolyte abnormalities: prior severe hypercalcemia and hypokalemia, now corrected but requires vigilance
Problem 5. Hematologic issues: chronic anemia during therapy, leukocyte fluctuations with G-CSF exposure, thrombosis/bleeding balance on antiplatelets
Problem 6. Diabetes mellitus with variable glycemic control and diabetic nephropathy
Problem 7. Chronic hepatitis B infection with high reactivation risk under anti-CD20 therapy
Problem 8. Infection risk and urinary abnormalities during immunochemotherapy
Problem 9. Gastrointestinal effects and constipation during therapy
Key insights / summary
Problem 1. Diffuse large B-cell lymphoma, stage III, C1 R-COP ongoing
Problem 2. Hypercalcemia of malignancy, improved
Problem 3. Hypokalemia (severe), persistent
Problem 4. Chronic kidney disease stage 3 with recent AKI, improving
Problem 5. Chronic hepatitis B on rituximab (high reactivation risk)
Problem 6. Diabetes mellitus with steroid-related glycemic variability
Problem 7. Cardiovascular disease and anthracycline fitness
Problem 8. Tumor lysis syndrome risk, currently low
Problem 9. Constipation and vincristine-related GI risk
Problem 10. Possible urinary tract inflammation vs colonization
Problem 11. Lipids and secondary prevention
Problem 12. Supportive care and device
Medications of note today (selected)
Follow-up labs/imaging checklist
[exam finding]
2025-11-18 Pathology - breast simple/partial mastectomy
2025-11-17 CXR
2025-11-17 Pathology - thyroid total/lobe
2025-11-17 Frozen Section
2025-11-17 Lymphoscintigraphy
2024-11-17 Body Composition Analysis
2025-10-31 2D transthoracic echocardiography
2025-10-24 Sonography - thyroid gland
2025-10-20 Tc-99m MDP bone scan
2025-10-17 CT - abdomen
2025-10-15 Mammography
2025-10-03 Pathology - breast biopsy (no need margin)
2024-09-24 Pathology - breast biopsy (no need margin)
2024-09-18 Merchant view (patella 45 0) bilat
2024-09-18 Knee bilat standing
2024-09-18 Sonography - breast
[consultation]
2025-12-08 Hemato-Oncology
2025-11-17 Rehabilitation
[MedRec]
2025-12-31 ~ 2026-01-01 POMR Hemato-Oncology Xia HeXiong
2025-12-07 ~ 2025-12-09 POMR General and Gastroenterological Surgery Zhang JianHui
2025-11-16 ~ 2025-11-21 POMR General and Gastroenterological Surgery Zhang JianHui
[surgical operation]
2025-12-08
2025-11-17 15:30
2025-11-17 12:30
2017-09-18
[chemotherapy]
[Subjective]
Pharmacist follow-up (caregiver report)
[Objective]
Cancer and pathology status
Cardiac baseline
Systemic therapy exposure
Recent laboratory data
[Assessment]
Chemotherapy tolerance and adverse-effect surveillance (TCH 2025-12-09; 2025-12-31)
Oncologic context impacting medication planning
[Plan / Recommendation]
Symptom management and counseling reinforcement (2026-01-07)
Therapy coordination and documentation improvements
[exam finding]
2025-10-13 2D transthoracic echocardiography
2025-10-12 Cardiac Catheterization
2025-10-11 12:30 ECG
2025-09-15 CT - abdomen
[MedRec]
2026-01-07, 2025-11-14 SOAP Cardiology Ke YuLin
2025-10-11 ~ 2025-10-15 POMR Cardiology Ke YuLin
2024-09-29 ~ 2024-10-04 POMR Urology Cai YaoZhou
2019-02-22 ~ 2019-02-25 POMR Cardiology Ke YuLin
[Subjective]
Pharmacist outreach and caregiver report
Patient-reported/expected symptoms to monitor at home (education content delivered via wife)
Lifestyle counseling content delivered
[Objective]
Index cardiovascular events and procedures
Key comorbidities and relevant history
Pertinent laboratory data around NSTEMI hospitalization
Current medication reconciliation (cardiology visit)
[Assessment]
Secondary prevention after NSTEMI status post PCI to distal RCA
Bleeding risk management on dual antiplatelet therapy with prior peptic ulcer disease
Bradycardia risk under beta-blocker therapy
HFpEF symptom surveillance and volume status monitoring
Lipid management and residual risk
Renal protection considerations post partial nephrectomy
[Plan / Recommendation]
Home monitoring plan (teach-back oriented)
Urgent referral triggers (reinforce with spouse and patient)
Medication management recommendations and counseling (current regimen based)
Lifestyle and rehabilitation recommendations
Care coordination questions for next cardiology visit (provide as a checklist)
Suggested self-care record template (for sustainability)
[exam finding]
2026-01-06 CT - chest
2025-11-27 Stroboscopy
2025-11-24 Voice Handicap Index, VHI
2025-11-24 Dysphagia Assessment
2025-11-24 Myofunctional therapy
2025-11-21 Swallowing video fluoroscopy
2025-10-27 Body composition analysis
2025-10-02 CXR
2025-09-05 CXR
2025-09-02 Pathology - thymus tumor
2025-09-02 CXR
2025-08-26 Flow Volume Chart
2025-08-04 Pathology - bronchus biopsy
2025-07-28 CT - chest
2025-07-24 CXR
2025-07-24 ECG
2025-06-05 Nasopharyngoscopy
[MedRec]
2025-08-31 ~ 2025-09-09 POMR Thoracic Surgery Xie MinXiao
[surgical operation]
2025-09-22
2025-09-02
2025-09-01
[radiotherapy]
[immunochemotherapy]
Key insights/summary
Problem 1. Thymic squamous cell carcinoma with suspected residual disease and pleural seeding (post-op + post-CCRT), initiating systemic therapy
Problem 2. Moderate left pleural effusion with pleural thickening/nodularity and dependent atelectasis, with risk of symptomatic respiratory compromise
Problem 3. Left hemidiaphragm paralysis with severe diaphragmatic crus atrophy (functional restriction and atelectasis driver)
Problem 4. Hematologic vulnerability during chemotherapy (prior CCRT cytopenias; current mild thrombocytopenia)
Problem 5. HBV core antibody positivity (resolved HBV) with risk of reactivation during systemic cancer therapy
Problem 6. Post-operative left vocal fold palsy with dysphonia; prior dysphagia complaint with reassuring swallow studies
Problem 7. Nutrition, body composition, and functional status during systemic therapy
[lab data]
2025-12-31 DNA STR fingerprint
2025-12-08 DNA STR fingerprint
2025-12-02 DNA STR fingerprint
2025-11-17 CMV IgM Nonreactive
2025-11-17 CMV IgM Value 0.15 Index
2025-11-17 CMV_IgG Reactive
2025-11-17 CMV_IgG Value 150.4 AU/mL
2025-11-17 Anti HTLV I/II Nonreactive
2025-11-17 Anti HTLV I/II Value 0.10 S/CO
2025-11-17 HIV Ab-EIA Nonreactive
2025-11-17 Anti-HIV Value 0.06 S/CO
2025-08-25 FLT3-D835 (BM) Undetectable
2025-08-21 FLT3/ITD (BM) Undetectable
2025-08-21 NPM1 (qual) (BM) Undetectable
2025-08-21 JAK2 (quan) 0.07 %
2025-08-14 Bone marrow cell morphology interpretation combined with
differential count
2025-08-14 Age/Sex 66/M
2025-08-14 Clinical information MDS
2025-08-14 Cellularity Hypo.
2025-08-14 M/E ratio increase
2025-08-14 Myelo.Blast 5 %
2025-08-14 Myelo.Pro. 0 %
2025-08-14 Myelo.Myelo. 7 %
2025-08-14 Myelo.Meta. 10 %
2025-08-14 Myelo.Band. 40 %
2025-08-14 Myelo.Seg. 20 %
2025-08-14 Lymphoid series 18 %
2025-08-14 Monocyte - %
2025-08-14 Plasma cell 1
2025-08-14 Megakaryocyte decrease LPF
2025-08-14 Ery.Pronormo. 1 %
2025-08-14 Ery.Nor.Basophilic 1 %
2025-08-14 Ery.Nor.Poly. 1 %
2025-08-14 Ery.Nor.Ortho. 3 %
2025-08-14 MPO +
2025-08-14 CAE +
2025-08-14 ANAE -
2025-08-01 CYTOGENETICS LABORATORY REPORT
2025-07-22 Reticulocyte count 0.630 %
2025-07-18 HLA A-high 11:01
2025-07-18 HLA A-high -
2025-07-18 HLA B-high 40:01
2025-07-18 HLA B-high 51:01
2025-07-18 HLA C-high 01:02
2025-07-18 HLA C-high 07:02
2025-07-18 HLA DRB1-high rsolution
2025-07-18 HLA DQ-high 03:01
2025-07-18 HLA DQ-high -
2025-07-18 HLA DRB1-high rsolution 2025-07-18 HLA DR-high 11:01
2025-07-18 HLA DR-high 12:01
2025-07-16 JAK2 (quan) <0.05 %
[exam finding]
2025-12-22 CXR
2025-12-07 ECG
2025-12-04, 2025-11-25 ECG
2025-11-20 CXR
2025-11-19 Sonography - abdomen
2025-11-17 ECG
2025-11-17 2D transthoracic echocardiography
2025-10-27 Lung Function Test
2025-09-29, 2025-09-08 CXR
2025-08-12 Pathology - bone marrow biopsy
2025-07-10 2D transthoracic echocardiography
2025-07-09 ECG
2025-07-09 CXR
2025-05-50 CXR
[MedRec]
2026-01-06, 2026-01-02 SOAP Hemato-Oncology Gao WeiYao
2025-11-16 ~ 2025-12-30 POMR Hemato-Oncology Gao WeiYao
2025-11-14 SOAP Hemato-Oncology Gao WeiYao
2025-11-03 Conditioning Regimen form the ward
2025-10-07 SOAP Hemato-Oncology Gao WeiYao
2025-09-29 ~ 2025-10-04 POMR Hemato-Oncology Gao WeiYao
2025-09-25 SOAP Hemato-Oncology Gao WeiYao
2025-09-05 ~ 2025-09-11 POMR Hemato-Oncology Gao WeiYao
2025-08-11 ~ 2025-08-18 POMR Hemato-Oncology Gao WeiYao
2025-07-09 ~ 2025-07-14 POMR Hemato-Oncology Gao WeiYao
2025-05-20 SOAP Hemato-Oncology Gao WeiYao
[consultation]
2025-12-10 Nephrology
2025-12-10 Psychosomatic Medicine
2025-12-04 Infectious Disease
2025-12-03 General and Gastroenterological Surgery
2025-11-18 Infectious Disease
2025-11-17 Vascular Surgery
2025-07-10 Metabolism and Endocrinology
[surgical operation]
2025-11-20
[chemotherapy]
[Subjective]
Pharmacist follow-up after discharge
Education delivered
[Objective]
Patient context and recent clinical course
Laboratory and monitoring signals supporting current pharmacist focus
Current discharge/OPD medication list relevant to education and monitoring (MedRec 2026-01-06)
[Assessment]
Post-allogeneic transplant surveillance concern: possible GVHD vs non-GVHD etiologies
[Plan / Recommendation]
GVHD symptom monitoring and escalation instructions (2026-01-07)
Medication adherence and drug-level monitoring
Symptom-directed supportive care recommendations
Communication and follow-up
Key Insights/Summary
Problem 1. Post-allogeneic PBSCT status and immune reconstitution (engraftment, GVHD prophylaxis, regimen-related toxicity)
Problem 2. Infection risk and pulmonary process (early suspected opportunistic pneumonia; current leukocytosis requires re-triage)
Problem 3. Hematologic complications post-transplant (anemia, thrombocytopenia, transfusion needs, and bleeding risk)
Problem 4. CMV prevention strategy and antiviral stewardship (high-risk recipient with negative viremia)
Problem 5. Regimen-related mucositis, GI symptoms (diarrhea, ileus risk), and nutrition support
Problem 6. Electrolyte and fluid disorders (hypernatremia episode, Mg/K/Phos abnormalities, dehydration vs overload balance)
Problem 7. Cardiopulmonary findings (tachycardia, troponin rise, cardiomegaly, oxygen requirement episodes)
Problem 8. Renal and hepatic function trends (drug dosing safety; calcineurin inhibitor monitoring)
Problem 9. Neuropsychiatric complications (hypernatremia-associated delirium; sedative/antipsychotic safety)
Problem 10. Hypertension and general supportive care (post-transplant stability, deconditioning risk)
[Sandimmun Neoral (ciclosporin) tube feeding]
The pharmaceutical manufacturer stated: “Because the medication inside the oral capsules has a chylous (milky) appearance, it may adhere to the tubing and cannot be fully administered. Therefore, for patients receiving enteral tube feeding, the use of an oral solution formulation or an injectable formulation is recommended.”
Key insights / summary (2025-12-08, day +10)
Problem 1. Post-allo-PBSCT aplasia with high infection risk and potential myelotoxic drugs
Problem 2. Neutropenic pneumonia with broad anti-infective therapy
Problem 3. Mucositis, GI dysfunction, diarrhea and nutritional compromise
Problem 4. Cardiorespiratory strain, possible myocardial injury and fluid overload
Problem 5. Electrolyte and metabolic disturbances under diuretics and TPN
Problem 6. Iron overload and hyperferritinemia in the post-transplant acute phase
C. Overall remarks
[Medication / treatment–related issues] as of 2025-12-05 (Day +7 after allo-PBSCT on 2025-11-28)
Problem 1. Profound post-transplant neutropenia with recent fever and broad-spectrum antimicrobials
Problem 2. GVHD prophylaxis with cyclosporine and methotrexate vs hepatic toxicity
Problem 3. Thrombocytopenia and anemia under intensive therapy
Problem 4. Electrolyte disturbances and nephrotoxic risk under cyclosporine, diuretics, and multiple IV drugs
Problem 5. Mucositis, diarrhea, and nutritional support
Problem 6. Hyperferritinemia and iron chelation strategy during transplant
Problem 7. Viral prophylaxis: HBV and CMV
Problem 8. G-CSF use and engraftment monitoring
Problem 9. Cardiovascular and volume-related considerations under current treatment
Key insights / summary as of 2025-12-04 (D+6 after allo-PBSCT)
Problem 1. Early post-allo-PBSCT marrow aplasia with profound neutropenia and thrombocytopenia
Problem 2. Neutropenic fever, dyspnea, and chest tightness under broad-spectrum antimicrobial escalation
Problem 3. Hepatic dysfunction and hyperbilirubinemia with risk of drug-induced liver injury and sinusoidal obstruction syndrome (SOS/VOD)
Problem 4. Fluid balance, dyspnea, and cardiovascular risk in a structurally abnormal but functionally preserved heart
Problem 5. Mucositis, oral ulcers, and GI toxicity (diarrhea and abdominal distension)
Problem 6. Electrolyte and mineral disturbances (hypomagnesemia, mild hypokalemia, low-normal Ca/P) under nephrotoxic and QT-prolonging therapies
Problem 7. Hyperferritinemia and iron overload under chelation therapy
Problem 8. GVHD prophylaxis and cyclosporine exposure
Problem 9. Renal function and nephrotoxic exposure with structural kidney lesions
Problem 10. Metabolic and nutritional status during intensive therapy
Overall, as of 2025-12-04 (D+6), the patient is in a high-risk but overall hemodynamically stable early post-allo-PBSCT phase. The main priorities are tight control of infection risk, vigilant monitoring of organ function (especially liver and heart), careful fluid and electrolyte management, optimization of GVHD prophylaxis, and supportive care for mucositis and nutrition, while temporarily de-emphasizing chronic issues such as iron overload until the acute phase has passed.
Key insights / summary as of 2025-12-02 (D+4 after allo-PBSCT, D0 = 2025-11-28)
Problem 1. Early post-allo-PBSCT status with profound cytopenias and engraftment risk
Problem 2. Hepatic dysfunction and VOD / drug-induced liver injury risk in the context of high ferritin and polypharmacy
Problem 3. Fluid overload and cardiovascular risk in a structurally abnormal heart
Problem 4. Anti-infective prophylaxis strategy (bacterial, fungal, viral, PCP) in severe neutropenia
Problem 5. Renal function and nephrotoxic drug exposure
Problem 6. Gastrointestinal toxicity: diarrhea, abdominal distension, and oral ulcers
Problem 7. Hyperferritinemia and iron overload management peri-transplant
Problem 8. Electrolyte balance and arrhythmia risk under QT-prolonging and nephrotoxic drugs
Problem 9. Sedative use (Eurodin (estazolam)) in an older, anemic, post-transplant patient
[Potential Medication Issues]
Problem 1. GVHD prophylaxis (Cyclosporin + Methotrexate) vs hepatic / renal toxicity
Problem 2. Iron chelation and urate-lowering therapy during early post-transplant period
Problem 3. Anti-infective prophylaxis: strengths, gaps, and duration
Problem 4. Fluid management and diuretic use in the setting of cardiac dilation
Problem 5. Electrolyte and QT risk under fluoroquinolone and diuretic therapy
Problem 6. Gastrointestinal and oral side effects related to therapy
Problem 7. Sedative (Eurodin (estazolam)) and delirium / fall risk
Problem 8. G-CSF and transfusion strategy
Key Insights / Summary (2025-11-24)
Problem 1. Conditioning-related cytopenias and anemia
Problem 2. Infection risk under profound immunosuppression
Problem 3. Electrolyte and renal function management during Melphalan/Fludarabine
Problem 4. Hyperferritinemia
Problem 5. Cardiac structural disease (dilated RA/RV/LV, moderate TR)
Problem 6. HBV infection under high immunosuppression
Problem 7. Fluid status and possible small bilateral pleural effusions
Problem 8. Liver function, biliary system, and SOS/VOD risk
Problem 9. Glycemic control under steroid and chemotherapy stress
Problem 10. GI toxicity and mucositis risk
Problem 11. Renal cysts and right renal stone
Problem 12. Sleep disturbance and benzodiazepine use
Problem 13. Hypertransfusion and potential iron overload
[for Interprofessional Practice (IPP) Meeting]
[letermovir]
Short answer
[Si Wu Tang & elevated blood bilirubin]
The patient drank Si Wu Tang (a traditional Chinese herbal soup) for several consecutive days starting around the “Start of Winter” solar term, and recently developed hyperbilirubinemia.
There is no clear scientific evidence that Si Wu Tang (Four Substances Decoction) directly increases blood bilirubin in healthy individuals. However, people with existing liver conditions or abnormal liver function should avoid tonic herbal formulas like Si Wu Tang, since they could place extra stress on the liver and worsen liver function, which may result in elevated bilirubin. Clinically, if liver enzymes or bilirubin levels are abnormal, practitioners often adjust or stop using formulas such as Si Wu Tang to protect liver health.79
Medical and Herbalist View
Research Findings
Guidance
Ref:
Key insights / summary
Problem 1. High-risk MDS / myeloid neoplasm with complex karyotype, preparing for allo-PBSCT
Problem 2. Current cytopenias (severe anemia, leukopenia) and transfusion support around conditioning
Problem 3. Infection risk, prophylaxis, and transplant-related viral issues (CMV, HBV, others)
Problem 4. Cardiovascular and pulmonary comorbidities and peri-transplant risk
Problem 5. Hepatic and renal function in relation to conditioning and concomitant medications
Problem 6. Metabolic and endocrine issues: pre-diabetes, overweight, and steroid-related risks
Problem 7. Sleep, mental health, and psychosocial support
Potential Medication Issues
[exam finding]
2026-01-05 Sonography - abdomen
2026-01-02 KUB
2025-12-22, 2025-12-18 CXR
2025-12-01 CXR
2025-11-24 Esophagogastroduodenoscopy, EGD
2025-11-19 MRI - liver, spleen
2025-09-15 Pathology - liver biopsy needle/wedge
2025-08-13 CT - abdomen
2025-06-24 CXR
2025-05-28 CT - abdomen
2025-03-06 CT - chest
2025-02-18 Hearing Test
2025-02-07 Pathology - liver biopsy needle/wedge
2025-01-24 Bronchodilator Test, BDT
2025-01-24 2D transthoracic echocardiography
2025-01-17 MRI - liver, spleen
2025-01-17 Pathology - colorectal polyp
2025-01-17 Pathology - stomach biopsy
2025-01-17 Colonoscopy
2025-01-17 Esophagogastroduodenoscopy, EGD
2025-01-09 CT - abdomen
2025-01-07 Sonography - abdomen
2024-10-15, 2024-07-23, 2024-04-30, 2024-02-06 Sonography - abdomen
2023-08-29 Sonography - abdomen
2023-07-05 Sonography - chest
2023-07-04 CXR
2023-07-03 Pathology - small intestine resection (non tumor)
2023-06-29 2D transthoracic echocardiography
2023-06-28 KUB
2023-06-28 Flow Volume Chart
2023-06-27 Small Intestine
2023-06-21 CT - abdomen
2023-06-19 Ascites tapping
2023-06-13 Sonography - abdomen
2023-06-10 05:53 CT - abdomen
2023-06-10 CT - brain
2023-03-15 CT - abdomen
2023-03-15 Esophagogastroduodenoscopy, EGD
2023-03-07 2D transthoracic echocardiography
2023-03-01 CT - abdomen
2023-02-27 Embolization (TAE) - abdomen
2023-02-27 CT - abdomen
2023-02-27 KUB
[MedRec]
2025-11-18 MultiTeam - Smoking cessation consultation
2025-11-12 ~ 2025-12-05 POMR Hemato-Oncology Yang MuJun
2023-06-10 ~ 2023-07-17 POMR General and Gastrointestinal Surgery Chen YenZhi
2023-02-27 ~ 2023-03-09 POMR General and Gastrointestinal Surgery Chen JiaHui
2023-02-19 ~ 2023-02-23 POMR Integrative Medicine Zhan WeiYu
2022-05-04 MultiTeam - Smoking cessation consultation
2022-05-02 ~ 2022-05-05 POMR Gastroenterology Li ZhongXian
2021-02-16 ~ 2021-02-17 POMR Colorectal Surgery Xiao GuangHong
[consultation]
[surgical operation]
2025-02-13
2023-07-02
2021-02-16
[immunochemotherapy]
Key insights/summary
Problem 1. Advanced intrahepatic cholangiocarcinoma with portal vein tumor thrombosis and metastatic disease (lung and non-regional nodes), progressive despite systemic therapy
Problem 2. Cirrhosis with portal hypertension and complications (splenomegaly, ascites, varices/portal hypertensive gastropathy), with episodic hepatic encephalopathy
Problem 3. Bilateral portal vein thrombosis (predominantly tumor thrombosis) with hepatic perfusion risk and portal hypertension worsening
Problem 4. Dyspnea with exertion in the setting of lung metastases, COPD physiology, and anemia
Problem 5. Acute kidney injury on CKD background risk (improving), with renal cysts and right renal angiomyolipoma
Problem 6. Electrolyte derangements: hyponatremia (improved), with ongoing risk for recurrence
Problem 7. Hematologic abnormalities: anemia and thrombocytopenia in advanced malignancy and portal hypertension
Problem 8. Pain (severe back pain history) and opioid regimen safety in cirrhosis/encephalopathy risk
Problem 9. Upper GI mucosal disease and variceal risk: severe reflux esophagitis/ECJ ulcers, portal hypertensive gastropathy, gastric varices
Problem 10. Gallstones/cholecystopathy and abdominal tenderness in a cirrhotic cancer patient
Problem 11. Cardiovascular comorbidity: moderate aortic regurgitation, left atrial dilation, systemic atherosclerosis
Problem 12. Tobacco use and COPD risk behavior
[exam finding]
2025-12-16 PTCD revision
2025-11-27 Cell block
2025-11-27 CT - abdomen
2025-10-28 CXR
2025-10-03 CXR
2025-09-23 Bladder Sonography
2025-08-20, 2025-08-10, 2025-07-17, 2025-06-25, 2025-06-11 CXR
2025-08-10 Sonography - abdomen
2025-07-22 CT - abdomen
2025-07-18 Abdomen - standing (diaphragm)
2025-06-27 Body fluid cytology - ascites
2025-06-26 Tc-99m MDP bone scan
2025-06-25 ECG
2025-06-03 Sonography - abdomen
2025-06-02, 2025-05-29 CXR
2025-05-27 CT - chest
2025-05-26 Cell block
2025-05-26 Sonography - chest
2025-05-25 CXR
2025-03-28 CXR
2025-03-27 Pathology - soft tissue tumor, extensive resection
2025-03-27 Body fluid cytology - ascites
2025-03-27, 2025-03-26 CXR
2025-02-27 CT - chest
2025-02-13 2D transthoracic echocardiography
2025-01-16 SONO - gynecology
2025-01-15 ACTOnco+ gene test
2025-01-03 CT - abdomen
2024-09-24 CT - abdomen
2024-09-02 2D transthoracic echocardiography
2024-08-19 CXR
2024-08-14 PET
2024-08-13 CXR
2024-07-17 Pathology - lung total/lobe/segmental
2024-07-17 Frozen section
2024-06-04 CT - abdomen
2024-03-02 CT - abdomen
2024-01-31 PET
2023-12-14 Gynecologic ultrasonography
2023-11-28 CT - abdomen
2023-08-30 Pathology - soft tissue tumor, extensive resection
2023-08-28 EGD
2023-08-07 CT - abdomen
2023-08-07 Gynecologic ultrasonography
2023-08-05 SONO - abdomen
[MedRec]
2025-12-14 ~ 2025-12-20 POMR Hemato-Oncology He JingLiang
2025-06-03 MultiTeam - Psycho-oncology
2023-09-24 ~ 2023-09-26 POMR Hemato-Oncology He JingLiang
2023-09-21 SOAP Obstetrics and Gynecology Chen GuoHu
2023-09-18 ~ 2023-09-21 POMR General and Gastrointestinal Surgery Li ChaoShu
2023-09-18 SOAP Medical Emergency He YaoCan
2023-09-14 SOAP Hemato-Oncology He JingLiang
2023-08-27 ~ 2023-09-08 POMR Obstetrics and Gynecology Chen GuoHu
2023-08-10 SOAP Obstetrics and Gynecology Chen GuoHu
2023-08-07 SOAP Obstetrics and Gynecology Chen GuoHu
2023-08-05 SOAP General and Gastrointestinal Surgery Chen YanZhi
2023-08-04 SOAP Gastroenterology Xu RongYuan
2020-10-15 ~ 2020-10-17 POMR General and Gastrointestinal Surgery Lai JieWen
2019-05-02 SOAP Obstetrics and Gynecology Hong ZhengXiu
[consultation]
2025-10-07 Dermatology
2025-09-22 Urology
2025-09-22 Radiation Oncology
2025-08-12 General and Gastroenterological Surgery
[surgical operation]
2025-08-13
2025-03-26
2024-07-17
2023-09-18
2023-08-29
2020-10-16
[radiotherapy]
[immunochemotherapy]
2025-12-15 - cisplatin 30mg/m2 40mg NS 250mL 2hr D1 + fluorouracil 800mg/m2 1100mg NS 500mL 23hr D1-2
2025-11-24 - cisplatin 30mg/m2 40mg NS 250mL 2hr D1 + fluorouracil 800mg/m2 1100mg NS 500mL 23hr D1-2
2025-11-03 - cisplatin 30mg/m2 40mg NS 250mL 2hr D1 + fluorouracil 800mg/m2 1100mg NS 500mL 23hr D1
2025-09-23 - cisplatin 30mg/m2 40mg NS 250mL 2hr D1 + fluorouracil 800mg/m2 2300mg NS 500mL 46hr
2025-09-22 - pembrolizumab 200mg NS 100mL 30min
2025-09-01 - pembrolizumab 200mg NS 100mL 30min
2025-08-11 - pembrolizumab 200mg NS 100mL 30min
2025-07-21 - pembrolizumab 200mg NS 100mL 30min
2025-07-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2025-06-25 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + [paclitaxel 30mg/m2 45mg cisplatin 30mg/m2 45mg gentamicin 40mg NaHCO3 2800mg NS 400mg] IP 1hr
2025-06-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2025-05-28 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + [paclitaxel 30mg/m2 45mg cisplatin 30mg/m2 45mg gentamicin 40mg NaHCO3 2800mg NS 400mg] IP 1hr
2025-05-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2025-05-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2025-04-28 - [paclitaxel 30mg/m2 45mg cisplatin 30mg/m2 45mg gentamicin 40mg NaHCO3 2800mg NS 400mg] IP 1hr
2025-04-25 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2025-03-26 - [liposome doxorubicin 30mg/m2 50mg D5W 90min + carboplatin AUC 5 550mg NS 250mL 90min] IP 90 min (HIPEC)
2025-01-23 - liposome doxorubicin 30mg/m2 40mg D5W 1hr + carboplatin AUC 5 400mg NS 250mL 2hr
2025-01-02 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 380mg NS 250mL 2hr
2024-12-10 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 380mg NS 250mL 2hr
2024-11-19 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 460mg NS 250mL 2hr
2024-10-28 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 560mg NS 250mL 2hr
2024-10-04 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 560mg NS 250mL 2hr
2024-09-09 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 590mg NS 250mL 2hr
2024-08-19 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 575mg NS 250mL 2hr
2024-06-04 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-05-15 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-04-18 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-03-27 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-03-02 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 520mg NS 250mL 2hr
2024-02-03 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
2024-01-13 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 440mg NS 250mL 2hr
2023-12-22 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-11-27 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-11-07 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 540mg NS 250mL 1hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-10-16 - paclitaxel 175mg/m2 245mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
2023-09-25 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
Key insights/summary
Problem 1. Progressive, treatment-refractory metastatic ovarian high-grade serous carcinoma with malignant ascites/pleural disease and suspected liver involvement
Problem 2. Functional decline, cancer cachexia, and poor oral intake with frailty
Problem 3. Renal vulnerability and electrolyte abnormalities in the setting of cisplatin exposure (hyponatremia, hypomagnesemia)
Problem 4. Chemotherapy-associated and malignancy-associated cytopenias (anemia, thrombocytopenia, leukopenia)
Problem 5. RUQ pain with suspected hepatobiliary involvement and catheter-related biliary/ascites drainage issues
Problem 6. Nocturia with sleep disruption and prior urinary frequency history
Problem 7. Chronic hepatitis B risk management during ongoing immunochemotherapy
Problem 8. Indwelling access devices and allergy history impacting inpatient safety
Dipeptiven 100 mL (alanyl glutamine 20g) nursing instruction (for this 46 kg patient, rounded to 50 kg)
Ref: https://assets.hpra.ie/products/Human/19814/4d286936-eeb3-467f-bb25-97fa82998b7b.pdf
Patient Summary
Problem 1. Advanced ovarian cancer (stage IV) with recent C6 gemcitabine/IP chemotherapy
Problem 2. Grade 3 anemia (HGB 6.5–8.0 g/dL)
Problem 3. Nutritional and GI symptom burden (nausea, appetite loss)
Problem 4. Tenckhoff catheter with IP chemotherapy delivery
Problem 5. Psycho-oncological stress and coping
The patient continues to receive medications for symptom control, anemia management, and antiviral prophylaxis. Active medications include Baraclude (entecavir) for Hepatitis B prophylaxis, Foliromin (ferrous sodium citrate) for anemia, and supportive medications like Acetal (acetaminophen) for pain and Granocyte (lenograstim) for neutropenia. The updated medication list suggests the ongoing management of anemia, potential bleeding risks, and chemotherapy-induced side effects, which align with the patient’s clinical status.
Problem 1. Persistent Anemia
Problem 2. Residual and Recurrent Malignancy
Problem 3. Thrombocytopenia and Bleeding Risk
Problem 4. Electrolyte Imbalance
[Medication Review]
Problem 1: Active Disease and Chemotherapy
Problem 2: Chemotherapy-Induced Nausea and Vomiting (CINV)
Problem 3: Viral Suppression and HBV Reactivation Risk
Problem 4: Pain, Anxiety, and Sedation
Problem 5: Uric Acid Management
Review Summary:
[Anemia]
Objective:
Assessment:
Recommendations:
Primary Findings:
Ongoing ovarian cancer (high-grade serous carcinoma) with peritoneal carcinomatosis and lymph node metastases (stage IIIC).
Chemotherapy-induced bone marrow suppression:
Current Concerns:
Recommendations:
[Analysis of CA-125 Trends and Correlation with Treatment Effects]
CA-125 is a key marker used to monitor disease progression and response to treatment in ovarian cancer, particularly in this case of high-grade serous carcinoma. Below is a detailed review of the patient’s CA-125 trend, correlated with treatment interventions and imaging findings:
Correlating Treatment Phases and Imaging
Clinical Comments on Treatment Effects
Recommendations:
Lab results remained largely unremarkable on 2023-12-21. Medication reconciliation confirmed no discrepancies.
Notably, the addition of bevacizumab to the paclitaxel + carboplatin regimen since 2023-11-07 has been associated with a sustained decline in CA-125 levels. Additionally, no adverse events related to bevacizumab, such as hypertension, gastrointestinal perforation, bleeding, or thromboembolic events, have been reported to date.
Upon review of the PharmaCloud database, the patient’s medication records are consistent with no discrepancies.
Following the cytoreductive surgery performed on 2023-08-29 and 2 subsequent cycles of the paclitaxel and carboplatin regimen administered on 2023-09-25 and 2023-10-16, there was a significant reduction in the tumor marker CA-125.
Avastin (bevacizumab) has been added to the treatment protocol beginning with the 3rd cycle. The patient should be closely monitored for signs of hypertension, gastrointestinal perforation, bleeding or thromboembolic events.
[exam finding]
2024-02-20 Hearing Test
2024-01-16 CXR
2024-01-16 Ultrasound-Guided Aspiration and Injection
2023-12-19 Ultrasound-Guided Aspiration and Injection
2023-11-30 Sonography - abdomen
2023-10-12 ECG
2023-10-03 Ultrasound-Guided Aspiration and Injection
2023-09-05 Ultrasound-Guided Aspiration and Injection
2023-08-07 Ultrasound-Guided Aspiration and Injection
2023-02-23 Pathology - bone marrow biopsy
2023-02-10 MRI - L-spine
2022-12-20 Bone densitometry - spine + hip
2022-12-13 CT - L-spine
2022-12-12 L-spine flex. & ext.
2022-12-12 KUB
[MedRec]
2026-01-04 ~ 2026-01-05 POMR Hemato-Oncology Gao WeiYao
2026-01-02 SOAP Hemato-Oncology Gao WeiYao
2024-06-19 ~ 2024-06-28 POMR Infectious Disease Hong BoBin
[consultation]
2024-06-21 Hemato-Oncology
[chemotherapy]
2024-12-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-12-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-11-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-11-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-11-01 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-10-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-10-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-10-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-10-04 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-09-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-09-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-09-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-08-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-08-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-07-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-07-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-06-14 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-06-07 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-05-31 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-05-24 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-05-17 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-05-10 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-05-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-04-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-04-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-04-12 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-04-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-03-29 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-03-22 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-03-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-02-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-02-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-01-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-01-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2024-01-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-12-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-11-10 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-11-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-10-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-10-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-09-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-09-22 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-09-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-09-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-07-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-07-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-06-05 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-06-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-05-29 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-05-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-05-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-05-12 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-05-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-05-05 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-04-24 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-04-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-04-17 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-04-14 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-04-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-31 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-24 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-10 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
2023-03-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC 1min
[medication]
Thado (thalidomide) 1# HS
Limeson (dexamethasone) 4mg 5# QD
Xgeva (denosumab) 120mg SC
Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
[lab data]
2025-11-20 BM chromosome analyz
[exam finding]
2026-01-02 KUB
2026-01-02 CXR
2026-01-02 External Eye Photography, Anterior Segment Photography
2025-12-31 Bedside echo (lung)
2025-12-22 CXR
2025-12-19 KUB
2025-12-04, 2025-11-28 Abdomen - standing (diaphragm)
2025-11-28 CXR
2025-11-18 Pathology - bone marrow biopsy
2025-11-17 Lung function test
2025-11-17 2D transthoracic echocardiography
2025-10-28 Pathology - bone marrow biopsy
2025-10-27 CT - abdomen
2025-10-20 Pathology - gallbladder (benign lesion)
2025-10-17 Sonography - abdomen
2025-10-16 CT - abdomen
2025-10-07 Esophagogastroduodenoscopy, EGD
2025-10-07 Sonography - abdomen
[MedRec]
2025-12-19 MultiTeam - Discharge Preparation
2025-12-19 ~ 2025-12-24 POMR Hemato-Oncology
2025-11-25 MultiTeam Psycho-Oncology
2025-11-14 ~ 2025-12-10 POMR Hemato-Oncology
2025-10-27 ~ 2025-10-31 POMR Infectious Disease Yang QingHui
[consultation]
2026-01-02 Ophthalmology
2025-11-24 Psychosomatic Medicine
2025-11-17 Cardiology
2025-10-27 Hemato-Oncology
2025-10-17 General and Gastroenterological Surgery
[surgical operation]
2025-10-17
2020-12-15
2020-11-24
[chemotherapy]
Key Insights/Summary (A)
Problem 1. Ongoing upper gastrointestinal bleeding with severe thrombocytopenia-related bleeding risk
Problem 2. High-risk MDS-IB2 on hypomethylating therapy with profound cytopenias and possible AML evolution risk
Problem 3. Suspected infection and pulmonary abnormalities in the setting of leukopenia
Problem 4. Ileus/constipation spectrum with recent radiographic ileus and prior fecal loading
Problem 5. Electrolyte and nutritional derangements (hyponatremia, hypomagnesemia/hypokalemia risk, hypoalbuminemia, hypocalcemia history)
Problem 6. Cardiovascular strain (sinus tachycardia, diastolic dysfunction signals, elevated NT-proBNP) in the context of anemia and lung findings
Problem 7. Left eye infection/inflammation consistent with canaliculitis/dacryocystitis spectrum
Problem 8. Depressed/anxious mood and coping distress affecting adherence and recovery
[exam finding]
2025-10-27 CXR
2025-10-17 CXR
2025-10-03 CXR
2025-08-11 Pathology - breast mastectomy with regional lymph nodes
2025-08-08 Frozen Section
2025-08-08 Lymphoscintigraphy
2025-08-07 2D transthoracic echocardiography
2025-08-06 Tc-99m MDP bone scan
2025-08-04 CT - chest
2025-07-28 Pathology - breast biopsy (no need margin)
2025-07-25 Pathology - lymphnode biopsy
2025-07-25 Pathology - breast biopsy (no need margin)
2025-05-26 2D transthoracic echocardiography
2025-05-22 L-spine AP + Lat (including sacrum)
2025-05-22 Knee Bilat
2025-05-20 Sonography - nephrology
[MedRec]
2025-12-26 ~ 2025-12-28 POMR Hemato-Oncology Yang MuJun
2025-12-01 SOAP Hemato-Oncology Yang MuJun
2025-10-02 ~ 2025-10-04 POMR Hemato-Oncology Yang MuJun
2025-08-25 SOAP General and Gastroenterological Surgery Chen YuTien
2025-08-07 ~ 2025-08-09 POMR General and Gastroenterological Surgery Chen YuTien
2025-06-15 ~ 2025-06-17 POMR Cardiac Surgery Song ZhenYu
2025-05-21 ~ 2025-05-28 POMR Nephrology Hong SiQun
[consultation]
2025-12-26 Nephrology
2025-08-07 Rehabilitation
2025-06-16 Nephrology
2025-05-21 Cardiac Surgery
[surgical operation]
2025-10-20
2025-08-08
2025-06-16
2025-05-22
[chemotherapy]
Key insights/summary
Problem 1. End stage renal disease on hemodialysis, dialysis access management, and chemotherapy coordination
Problem 2. Early-stage hormone receptor-positive breast cancer post breast-conserving surgery on adjuvant chemotherapy, planning for radiotherapy and endocrine therapy
Problem 3. Chemotherapy-related myelosuppression and anemia (multifactorial: ESRD, chemotherapy, and possible occult blood loss)
Problem 4. Cardiac disease and cardiotoxicity risk during anthracycline and fluorouracil exposure (HF history, LVH/diastolic dysfunction, cardiomegaly)
Problem 5. Pulmonary abnormalities (interstitial lung disease/fibrosis, ground-glass opacities) and differential including fluid overload vs infection vs drug effect
Problem 6. Mineral and electrolyte disorders of ESRD (hypocalcemia, hyperphosphatemia, acid-base risk) with bone health concerns
Problem 7. Hypothyroidism with biochemical under-treatment
Problem 8. Vascular access and device-related infection/thrombosis risk (Port-A, AVG, prior perm-cath)
Problem 9. Possible gastrointestinal bleeding (positive iFOB) in the context of anemia
[exam finding]
2025-12-29, 2025-12-22 CXR
2025-12-19 Sonography - chest
2025-12-17 Bronchoscopy
2025-12-17 Sonography - chest
2025-12-08, 2025-12-03 CXR
2025-11-27 CT - chest
2025-11-12 Sonography - chest
2025-11-11 ECG
2025-11-03, 2025-10-27 CXR
2025-09-24 Pathology - colon biopsy
2025-09-23 Colonoscopy
2025-09-16 ACTOnco+
2025-09-16 CXR
2025-09-10 Pathology - bronchus biopsy
2025-09-08 Pathology - lymphnode biopsy
2025-09-05 2D transthoracic echocardiography
2025-09-01 CT - chest
2025-08-11 CT - neck
2025-08-11 Nasopharyngoscopy
2025-08-07 MRI - C-spine
[MedRec]
2025-08-18 MultiTeam - Hospice Care
2025-08-13 Shared Decision-Making, SDM
2025-08-09 ~ 2025-12-12 POMR Hemato-Oncology Yang MuJun
[surgical operation]
2025-09-08
[immunotherapy]
[medication]
Tagrisso FC (osimertinib 80mg) 1# QDAC
Key insights / summary
Problem 1. Acute on chronic hypoxic respiratory failure with tumor-related airway/pleural disease
Problem 2. Metastatic lung adenocarcinoma, EGFR exon 19 deletion with high EGFR amplification; on Tagrisso (osimertinib) plus Rybrevant (amivantamab)
Problem 3. Recent severe infections: VRE faecium bacteremia; Candida albicans UTI; sputum PDR Acinetobacter; CREC colonization
Problem 4. Lower GI bleeding due to rectal ulcers with constipation risk
Problem 5. Transaminitis, improving
Problem 6. Chronic normocytic anemia, improved
Problem 7. Electrolyte and metabolic issues: hyponatremia, low calcium, low albumin; sarcopenia biasing eGFR
Problem 8. Pleural and pericardial effusions
Problem 9. Symptom and supportive care: pain, sleep, nutrition
Current medication list highlights
[exam finding]
2025-11-20 Portable 24hr ECG
2025-10-31 ECG
2025-09-23 2D transthoracic echocardiography
2025-08-29 Pathology - breast simple/partial mastectomy
2025-08-29 Pathology - breast simple/partial mastectomy
2025-08-28 Frozen Resection
2025-08-27 ECG
2025-08-27 Body Composition Analysis
2025-08-06 PET
2025-07-29 MRI - breast
2025-07-25 Tc-99m MDP bone scan
2025-07-07 CT - chest
2025-06-23 Pathology - breast biopsy (no need margin)
2025-06-23 Pathology - breast biopsy (no need margin)
2025-01-02 KUB
2023-03-24 Sonography - abdomen
2022-04-19 Brainstem Auditory Evoked Potential, BAEP
2022-04-19 Neurosonography
2020-06-12 Peripheral Vascular Sonography - upper limbs artery
Indication: suspected radial artery occlusion after cath exam
Report_1
Report_2
Conclusions
2020-05-25 Cardiac Catheterization
2025-05-25 CXR
2025-05-25 2D transthoracic echocardiography
2025-05-24 ECG
2020-05-23 ECG
[MedRec]
2025-12-26 ~ 2025-12-29 POMR Hemato-Oncology Yang MuJun
2025-09-15 SOAP General and Gastrointestinal Surgery Chen YenZhi
2025-09-02 MultiTeam - Psycho-oncology
2025-08-27 ~ 2025-09-03 POMR General and Gastrointestinal Surgery Chen YenZhi
2020-05-24 ~ 2020-05-28 POMR Cardiology Duan DeMin
[surgical operation]
2025-09-18
2025-08-28
[immunochemotherapy]
[Subjective]
Pharmacist Follow-up
[Objective]
Cancer and treatment timeline
Cardiac evaluation (baseline and intercurrent events)
Laboratory and metabolic context relevant to fatigue and cardiopulmonary symptoms
[Assessment]
Chemotherapy tolerance and adverse effects (TCHP with Phesgo)
Cardiac safety during HER2-directed therapy and chemotherapy
Metabolic monitoring need
[Plan / Recommendation]
Symptom triage and immediate safety
Cardio-oncology coordination (suggested improvements to current workflow)
Fatigue management
Glucose and cardiovascular risk monitoring
Patient education reinforcement
Key Insights/Summary
Problem 1. Possible acute coronary syndrome history / chest pain evaluation and cardiac risk
Problem 2. Marked leukocytosis with left shift (resolved) vs infection/inflammation/stress response
Problem 3. Hyperglycemia episode and cardiometabolic risk (dyslipidemia, ASCVD risk)
Problem 4. Renal function and electrolyte balance (currently stable)
Problem 5. Hematuria on urinalysis (needs follow-up if persistent)
Clinical Counseling Brief (Senior Clinical Pharmacist MTM) - 2025-12-31
[exam finding]
2025-12-30 CXR
2025-12-06 KUB
2025-10-17 Tc-99m MDP bone scan
2025-10-16 MRI - larynx
2025-10-15 PD-L1 (28.8)
2025-10-14 CT - chest
2025-09-08 CXR
2025-09-01 KUB
2025-08-15 Abdomen - Standing (Diaphragm)
2025-08-08 KUB
2025-06-17 Pure Tone Audiometry, PTA
2025-06-16 MRI - larynx
2025-06-13 Laryngoscopy
2025-06-11 CXR
2025-06-10 Pathology - tongue biopsy
2025-06-09 MRI - T-spine
2025-06-09 Sonography - thyroid gland
2025-06-09 Laryngoscopy
2025-06-05 Nasopharyngoscopy
2025-06-05 Lung Function Test
2025-06-04 Pathology - esophageal biopsy
2025-06-04 2D transthoracic echocardiography
2025-06-04 Miniprobe Endoscopic Ultrasound
2025-06-04 Sonography - abdomen
2025-06-03 PET
2025-06-03 CXR
2025-06-02 Tc-99m MDP bone scan
2025-05-30 MRI - brain
2025-05-27 CT - chest
2025-05-26 Pathology - esophageal biopsy
2025-05-23 Esophagogastroduodenoscopy, EGD
[MedRec]
2025-12-03 SOAP Hemato-Oncology Xia HeXiong
2025-08-01 SOAP Radiation Oncology Wang YuNong
2025-05-29 ~ 2025-07-09 POMR Hemato-Oncology Xia HeXiong
[consultation]
2025-12-31 Thoracic Surgery
2025-12-22 Thoracic Surgery
2025-06-09 Hemato-Oncology
2025-06-06 Radiation Oncology
2025-06-05 Ear Nose Throat
2025-05-29 Gastroenterology
[surgical operation]
[radiotherapy]
[chemotherapy]
Key insights/summary
Problem 1. Metastatic esophageal squamous cell carcinoma on multimodality therapy, timing of PF4 cycle and restaging
Problem 2. Acute cough with radiographic LLL abnormality and leukocytosis, rule out lower respiratory tract infection vs atelectasis vs tumor
Problem 3. Feeding jejunostomy tube dysfunction requiring revision; perioperative optimization
Problem 4. Malnutrition/cachexia and poor functional status limiting treatment tolerance
Problem 5. T10 vertebral metastasis with possible progression; pain control and skeletal-related event prevention
Problem 6. Cardiomegaly and small effusions; evaluate for cardiomyopathy, pericardial effusion progression, or volume-related changes
Problem 7. Macrocytic anemia, chronic and fluctuating; clarify etiology and manage peri-treatment needs
Problem 8. Hepatitis B core antibody positive with antiviral prophylaxis; mild transaminitis
Problem 9. Renal function and cisplatin nephrotoxicity risk; electrolyte surveillance
Problem 10. Cisplatin-associated ototoxicity risk with baseline sensorineural hearing loss
Problem 11. Symptom management and supportive medications (cough, GI symptoms, constipation/diarrhea balance)
Key Insights / Summary
Problem 1. Healthcare-associated pneumonia due to Citrobacter koseri, improving on therapy
Note for Problem 1 (not posted) - Healthcare-associated pneumonia (HCAP) in this simulated patient is suspected and documented because of several converging factors:
Note for Problem 1 (not posted) - Let’s walk through how classifying this pneumonia as healthcare-associated directly influences empiric antibiotic strategy compared with standard community-acquired pneumonia (CAP).
Note for Problem 1 (not posted) - Stepwise Antibiotic Decision Algorithm (For oncology patients with indwelling devices + nursing facility exposure, suspected pneumonia)
Problem 2. Sepsis/SIRS risk associated with pneumonia, currently improving
Problem 3. Advanced esophageal squamous cell carcinoma on PF4, treatment timing amid infection
Problem 4. Protein-energy malnutrition and cachexia risk (below not posted)
Problem 5. Chemotherapy-related cytopenias, now recovering
Problem 6. Electrolyte and renal-hepatic function stewardship
Problem 7. Abnormal urinalysis (glucosuria 3+, protein 1+) with normal serum glucose
Problem 8. Jejunostomy and Port-A device care; constipation and analgesia balance
Problem 9. Medication stewardship and prophylaxis
Planned checks and timeline
The patient is a 73-year-old male with stage IVA squamous cell carcinoma of the upper to lower esophagus, with metastasis to thyroid and T10 vertebral body, status post feeding jejunostomy and left Port-A insertion on 2025-06-11. He completed concurrent chemoradiotherapy (2025-06-27 to 2025-08-08) and one cycle of PF4 chemotherapy (2025-07-01 to 2025-07-04), now admitted for further chemotherapy. His nutritional status is poor (BMI 16.4), with hypoalbuminemia (3.1 g/dL on 2025-08-08) and mild anemia (Hgb 10.4 g/dL on 2025-08-08). Vital signs are mostly stable, without current signs of infection. Electrolytes show mild hyponatremia (Na 133 mmol/L on 2025-08-08) and borderline low calcium (2.06 mmol/L). Pain and constipation are being managed with scheduled laxatives and PRN analgesics.
Problem 1. Advanced esophageal squamous cell carcinoma (stage IVA) with metastases
Problem 2. Protein-energy malnutrition and low BMI
Problem 3. Normocytic anemia
Problem 4. Electrolyte abnormalities (mild hyponatremia, borderline hypocalcemia) (not posted)
Problem 5. Constipation
[exam finding]
[MedRec]
2025-11-21 ~ 2025-12-14 POMR Cardiac Surgery Yang KaiWen
[exam finding]
2025-12-11 Pathology - liver biopsy needle/wedge
2025-12-09 Sonography - abdomen
2025-11-27 KUB
2025-11-26 MRI - brain
2025-11-18 Pathology - bone marrow biopsy
2025-11-13 2D transthoracic echocardiography
2025-11-13 PET
2025-11-11 Lung function test
2025-10-31 CT
2025-10-22 Pathology - stomach biopsy (Y1)
2025-06-05 Sacrum & Coccyx:
2025-05-26 L-spine AP + Lat (including sacrum)
[MedRec]
2025-12-29 SOAP Hemato-Oncology Liu YiSheng
2025-12-06 ~ 2025-12-26 POMR Hemato-Oncology Liu YiSheng
2025-11-11 ~ 2025-11-27 POMR Hemato-Oncology Liu YiSheng
2025-10-23 SOAP Gastroenterology Li XianZhong
2018-03-05 ~ 2018-03-21 POMR Plastic Surgery Zhang MengZong
2017-06-07 ~ 2017-06-09 POMR Plastic Surgery Lu ChunDe
[immunochemotherapy]
[Subjective]
Patient contact and adherence (pharmacist follow-up)
[Objective]
Hematology and infection markers
Renal and hepatic function relevant to medication safety
Active treatment and supportive medications (recent plan)
[Assessment]
Febrile neutropenia risk and current symptom interpretation
Medication-related adverse effects and safety issues
[Plan / Recommendation]
Neutropenia workflow and patient safety escalation plan
Medication optimization and counseling
Chemotherapy-induced peripheral neuropathy (CIPN) monitoring and escalation
Additional pharmacist-driven improvements
Key insights / summary
Problem 1. Febrile neutropenia / suspected infection with recent bronchopneumonia history
Problem 2. Chemotherapy course optimization and response assessment in high-risk DLBCL
Problem 3. Chemotherapy-associated neutropenia and hematologic support strategy
Problem 4. Liver lesions and discordant biopsy result (granulation tissue only)
Problem 5. Hepatitis B reactivation prophylaxis during rituximab-based therapy
Problem 6. Electrolyte and metabolic issues (hypocalcemia history, uric acid fluctuation)
Problem 7. Gastrointestinal issues: gastric lymphoma involvement, GERD/esophagitis, diarrhea, and medication safety
Problem 8. Hemorrhoids (fourth degree) and constipation risk in the setting of vincristine and opioids
Problem 9. CNS finding and syncope history
Problem 10. Medication safety and interaction burden (sedation, acetaminophen total dose, antibiotic adverse effects)
Key insights / summary
Problem 1. Fever in an immunocompromised patient after R-CHOP
Problem 2. High-risk stage IV diffuse large B cell lymphoma under R-CHOP – early response and ongoing strategy
Problem 3. Chronic normocytic anemia
Problem 4. Hepatic involvement, prior transaminitis and LDH elevation – currently improving
Problem 5. Resolved HBV infection under Vemlidy (tenofovir alafenamide) prophylaxis during rituximab therapy
Problem 6. Supportive care issues: GI symptoms, mucositis, constipation, insomnia and future chemotherapy toxicities
Overall, the patient currently appears clinically stable with improving infection markers and good early biochemical response to C1 R-CHOP. The priorities are to complete and then de-escalate antibiotic therapy appropriately, prepare safely for subsequent R-CHOP cycles with thorough supportive care, closely monitor organ functions and HBV status, and perform timely imaging to confirm oncologic response.
[Potential Medication Issues]
Anti-infective therapy (Tapimycin (piperacillin/tazobactam), prior cefotaxime, future needs)
Antiviral prophylaxis for resolved HBV infection (Vemlidy (tenofovir alafenamide))
R-CHOP chemotherapy strategy and supportive G-CSF use
Analgesia and antipyretics (Acetal (acetaminophen) and Tramacet (tramadol/acetaminophen))
Acid suppression and prokinetic therapy (Pariet (rabeprazole), Dexilant (dexlansoprazole), Mosapin (mosapride))
Constipation management (Through (sennoside) and opioid/VCR-related constipation)
Sedatives and fall/syncope risk (Anxiedin (lorazepam))
Hemostatic and venotonic agents (Tranexamic acid, Dailon, Alcos-Anal ointment)
Prophylaxis and vaccination considerations
Overall, the major medication- and treatment-related concerns are appropriate but potentially over-extended broad-spectrum antibiotic use, cumulative acetaminophen and sedative burden, the need to refine and support high-risk R-CHOP therapy (including antiviral prophylaxis and possible CNS prophylaxis), constipation and GI protection strategies, and careful reassessment of hemostatic and benzodiazepine use. Addressing these will improve safety while maintaining curative-intent lymphoma management.
[exam findings]
2025-11-12 CT - abdomen
2025-09-09 ECG
2025-07-01 CT - abdomen
2025-03-25 CT - abdomen
2024-11-12 CT - abdomen
2024-10-29 Tc-99m MDP bone scan with SPECT
2024-08-03 CT - abdomen
2024-04-18 CT - abdomen
2024-01-04 MRI - pancreas
2024-01-04 Pathology - pancreas biopsy
2023-12-22 CT - abdomen
2023-12-19 EGD
[MedRec]
2025-09-10 ~ 2025-09-13 POMR Hemato-Oncology He JingLiang
2024-01-21 ~ 2024-01-25 POMR Hemato-Oncology He JingLiang
2024-01-01 ~ 2024-01-05 POMR Gastroenterology Li ZhongXian
[chemotherapy]
[note]
Chemotherapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Cycle length: 14 days.
Regimen
Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
Cycle length: 14 days.
Regimen
Key insights / summary
Problem 1. Progressive pancreatic ductal adenocarcinoma with suspected peritoneal carcinomatosis and malignant ascites
Problem 2. Severe hypotonic hyponatremia in the setting of malignancy, ascites, and recent vomiting
Problem 3. Malignant ascites with abdominal distention/pain and risk of infectious peritonitis
Problem 4. Chemotherapy course management and treatment-related toxicity risk in a frail older adult
Problem 5. Pain, nausea/vomiting, and bowel regimen (symptom control)
Problem 6. Malnutrition/cachexia risk and inpatient nutritional support
Problem 7. Chronic hepatitis B exposure with antiviral prophylaxis during chemotherapy
Problem 8. Cardiac rhythm disturbances (PVC/PAC) and conduction abnormality
Current medication reconciliation snapshot (for clinical context, not a substitute for formal orders)
[stable disease and consistent CA199 levels under FOLFIRINOX]
A CT scan on 2024-08-03, compared to 2024-04-18, showed stable disease. CA-199 levels have remained around 500 U/mL over the past 2 months, and other lab results on 2024-08-24 were generally normal. The patient is tolerating the FOLFIRINOX regimen well, and no medication issues have been identified.
Abdominal CT scan performed on 2024-04-18, revealed stable pancreatic body cancer without further invasion into adjacent structures. Additionally, lab results showed a continued decline in CA-199 levels. These findings suggest that the current FOLFIRINOX treatment regimen is still effective.
No medication discrepancies were identified.
[clearance for 4th FOLFIRINOX session based on lab results]
Laboratory tests conducted on 2024-03-28 showed all key indicators, including blood counts, electrolytes, and liver and kidney functions, were grossly within normal ranges, allowing for the 4th session of FOLFIRINOX to proceed without medical objections.
A comprehensive examination of the patient’s medication list in both the HIS5 and PharmaCloud databases confirmed consistency and accuracy.
[reconciliation]
The CA-199 level has declined relative to the previous month’s data. Laboratory results from 2024-03-06 were generally within normal limits, leading to the administration of the third cycle of FOLFIRINOX on the same day.
A thorough review of the HIS5 and PharmaCloud databases revealed no discrepancies in medication.
[rising CA-199 in newly-started FOLFIRINOX Regimen, further investigation needed. unremarkable labs & no med discrepancies]
This patient initiated FOLFIRINOX treatment in late 2024-01 and the current hospitalization pertains to the second cycle. While other lab findings on 2024-02-15 were unremarkable and no medication discrepancies were identified, ongoing elevation of the tumor marker CA-199 warrants further investigation.
[exam finding]
2025-12-29 CXR
2025-12-26 L-spine flex. & ext. (including sacrum)
2025-12-24 MRI - L-spine
2025-12-23 MRI - brain
2025-12-16 Bladder Sonography
2025-12-16 Uroflowmetry
2025-12-16 Transrectal Ultrasound of Prostate, TRUS-P
2025-12-08 L-spine AP + Lat (including sacrum)
2025-12-05 Radiofrequency Ablation - liver tumor
2025-12-04 ECG
2025-12-03 PET
2025-11-26 Sonography - abdomen
2025-11-19 CT - facial bone
2025-10-29 CT - abdomen
2025-10-28 Sigmoidoscopy
2025-09-23 T- L-spine AP + Lat
2025-09-23 C-spine flex. & ext.
2025-09-23 2D transthoracic echocardiography
2025-09-02 MRI - liver, spleen
2025-08-29 PET
2025-07-29 Sigmoidoscopy
2025-06-18 Sonography - abdomen
2025-05-22 Knee Lt
2025-04-28 MRI - liver, spleen
2025-04-22 Sigmoidoscopy
2025-04-02 PET
2025-03-24 ECG
2025-02-17 CXR
2025-02-13 CT - brain
2025-02-11 ECG
2025-02-11 CT - knee Lt
2025-02-11 CT - brain
2025-02-11 Shoulder Rt
2025-02-11 Knee Lt
2025-02-11 CXR
2025-01-20 Bladder Sonography
2025-01-20 Uroflowmetry
2025-01-06 Sonography - urology
2024-12-24
2024-12-23 CXR
2024-12-20 2D transthoracic echocardiography
2024-12-19 ECG
2024-12-18 PET
2024-11-27 MRI - pelvis
2024-11-14 CT - abdomen
2024-11-06 Pathology
2024-11-06 Pathology
2024-11-05 Colonoscopy
2024-06-07 2D transthoracic echocardiography
2024-04-22 Nerve Conduction Velocity, NCV
2023-11-23 2D transthoracic echocardiography
2023-09-06 ECG
2023-08-01 2D transthoracic echocardiography
[MedRec]
2025-12-04 ~ 2025-12-08 POMR Gastroenterology Wang JiaQi
2025-12-01, 2025-09-08, 2025-06-16 SOAP Cardiology Zhang HengJia
2025-05-14 ~ 2025-05-19 POMR Hemato-Oncology Lin YiTing
2025-02-11 ~ 2025-02-26 POMR Orthopedics Huang ZhenWen
2024-12-19 ~ 2024-12-28 POMR Hemato-Oncology Lin YiTing
2023-05-15 ~ 2023-05-29 POMR Cardiac Surgery Shen DaZhong
2023-05-03 ~ 2023-05-05 POMR Cardiology Zhang HengJia
[consultation]
2025-05-16 General and Gastroenterological Surgery
2025-02-12 Neurosurgery
2024-12-20 Gastroenterology
2023-08-01 Cardiology
2023-05-04 Cardiac Surgery
[radiotherapy]
[chemotherapy]
Key insights / summary
Problem 1. Metastatic rectal cancer on systemic therapy, s/p local liver therapy
Problem 1a. Metastatic rectal adenocarcinoma (RAS/BRAF wild-type, pMMR/MSS), on Avastin (bevacizumab) + FOLFIRI after oxaliplatin-based therapy; s/p liver MWA
Problem 2. Chest tightness during chemotherapy admission; rule-out cardiopulmonary etiologies (ACS, PE, HF, arrhythmia)
Problem 3. Anticoagulation management in permanent atrial fibrillation during Avastin (bevacizumab) chemotherapy
Problem 4. Hypokalemia and electrolyte-related arrhythmia risk
Problem 5. Chemotherapy-associated cytopenias (current mild leukopenia, anemia; platelet reserve borderline)
Problem 6. Mucositis, grade II with oral ulcers; infection and nutrition risk
Problem 7. Hepatitis B reactivation prophylaxis in anti-HBc positive patient on chemotherapy
Problem 8. Type 2 diabetes mellitus on SGLT2 inhibitor during inpatient chemotherapy
Problem 9. Heart failure with mildly reduced EF and valvular history; cardiomegaly on imaging
Problem 10. Lower urinary tract symptoms / bladder dysfunction and BPH-related therapy
Problem 11. Pain and supportive medications; medication rationalization opportunities
[exam finding]
2025-11-25 Scrotal (Male Genital) Ultrasound
2025-11-21 ECG
2025-11-04 ECG
2025-11-04 CXR
2025-10-30 Pure Tone Audiometry, PTA
2025-10-29 MRI - brain
2025-10-28 Tc-99m MDP bone scan
2025-10-27 Lung Function Test
2025-10-27 2D transthoracic echocardiography
2025-10-23 Pathology - duodenum biopsy
2025-10-23 Pathology - colorectal biopsy
2025-10-22 Colonoscopy
2025-10-22 Esophagogastroduodenoscopy, EGD
Esophageal ulcer, EG junction
Duodenal ulcer, multiple, s/p endoscopic hemostasis and biopsy
Deformed gastric antrum.
PATHOLOGIC DIAGNOSIS
MACROSCOPIC EXAMINATION
MICROSCOPIC EXAMINATION
2025-10-15 MRI - liver spleen
2025-10-13 ECG
2025-10-13 Sonography - abdomen
[MedRec]
2025-12-05 SOAP Hemato-Oncology Lin YiTing
2025-11-21 ~ 2025-11-27 POMR Hemato-Oncology Lin YiTing
2025-10-11 ~ 2025-11-13 POMR Hemato-Oncology Lin YiTing
2025-10-01 SOAP Gastroenterology Gong ZiXiang
[consultation]
2025-11-24 Urology
2025-11-03 Family Medicine
2025-10-31 Dentistry
2025-10-28 Vascular Surgery
2025-10-16 Hemato-Oncology
[chemotherapy]
Key Insights/Summary (A)
Problem 1. Metastatic high-grade neuroendocrine carcinoma with dominant liver involvement and suspected skeletal metastases
Problem 2. Liver dysfunction and cholestasis from tumor burden, with improved jaundice but persistent hypoalbuminemia
Problem 3. EP chemotherapy toxicity surveillance and supportive care (renal, electrolyte, marrow, ototoxicity)
Problem 4. Thromboembolism risk and cardiopulmonary evaluation in the setting of malignancy and tachycardia
Problem 5. Recurrent infection risk and prior documented bacteremia/UTI/cellulitis in an immunocompromised host
Problem 6. Normocytic anemia with prior GI bleeding history
Problem 7. Edema (bilateral leg and scrotal), hypoalbuminemia, and diuretic-associated electrolyte losses
Problem 8. GI mucosal disease: esophageal ulcer and multiple duodenal ulcers with prior bleeding
Problem 9. Type 2 diabetes mellitus and inpatient glucose variability
Problem 10. Essential hypertension and cardiovascular risk management
Problem 11. HBV reactivation prophylaxis (resolved HBV infection pattern) during chemotherapy
[exam finding]
2025-11-11 CXR
2025-11-10 PD-L1 (28.8)
2025-11-03 Pathology - stomach biopsy
2025-11-03 Sonography - abdomen
2025-10-31 CT - abdomen
2025-10-31 Esophagogastroduodenoscopy, EGD
[MedRec]
2025-12-27 MultiTeam - Ostomy care
2025-12-15 SOAP Hemato-Oncology Yang MuJun
2025-12-05 ~ 2025-12-11 POMR Hemato-Oncology Yang MuJun
2025-10-31 ~ 2025-11-19 POMR Hemato-Oncology Yang MuJun
[consultation]
2025-11-04 General and Gastroenterological Surgery
2025-11-03 Hemato-Oncology
[surgical operation]
2025-11-06
[chemotherapy]
Key insights / summary
Problem 1. Metastatic gastric antrum adenocarcinoma with gastric outlet obstruction and liver metastases, on first-line immunochemotherapy
Problem 2. Cancer-associated malnutrition, cachexia, and gastric outlet obstruction requiring enteral support; jejunostomy-site complications
Problem 3. Treatment-related and disease-related hematologic issues: prior severe anemia and episodic leukopenia/neutropenia
Problem 4. Electrolyte and volume disturbances in the context of malnutrition, diarrhea, and supportive infusions
Problem 5. Chronic hepatitis B exposure (anti-HBc positive) and antiviral prophylaxis during immunochemotherapy
Problem 6. Severe reflux esophagitis (LA grade D) and upper GI bleeding risk in the setting of malignancy
Problem 7. Vascular risk and hemodynamic observations (atherosclerosis; episodic tachycardia)
[Pariet (rabeprazole) tube feeding]
Pariet (rabeprazole 20 mg) is an enteric‑coated tablet and should be swallowed whole; enteric‑coated tablets are not recommended for feeding tube administration.
Please consider switching to Nexium (esomeprazole 40mg) which can be tube fed via simple suspension methond (SSM).
[exam finding]
2025-12-26 2D transthoracic echocardiography
2025-12-24 PET
2025-12-08 Toe(s) RT:
2025-11-11 CXR
2025-11-03 Foot Rt
2025-10-30 Foot Rt
2025-10-17 Sonography - urology
2025-10-15 Sono-guided injection - femoral triangle block
Right sartorius muscle was view and the femoral artery was identified.
Needle tip was inserted, the medial femoral cutaneous nerve was found
4ml 2% Xylocaine + 16ml N/S was injected.
2025-09-24 Bone densitometry - spine + hip
2025-09-24 Nerve Conduction Velocity, NCV
2025-09-23 Knee Bilat
2025-09-22 KUB
2025-09-20 MRI - L-spine
2025-09-19 MRA - brain
2025-09-17 Tc-99m MDP bone scan
2025-09-17 KUB
2025-09-16 CT
2025-09-16 Pathology - stomach biopsy
2025-09-15 20:05 CT
2025-09-15 Standing KUB
2025-09-15 00:17 CT
2025-09-15 00:15 ECG
2025-09-15 Esophagogastroduodenoscopy, EGD
2025-08-28 MRI - pelvis
2025-08-25 KUB
2025-07-18 Kidney Sonography - urology
2025-06-10 CT - neck
2025-06-09 Pathology - lymphnode biopsy
2025-06-03 CTA - chest
2025-05-28 Sonography - vein
2025-05-26 CXR
2025-05-22 Pathology - uterus (with or without SO) neoplastic (Y1)
2025-05-21 ECG
2025-05-14 16:12 Pathology - endometrium curretage/biopsy
2025-05-14 14:27 Pathology - lymphnode biopsy (Y2)
2025-05-09 Sonography - vein
2025-05-08 MRI - pelvis
2025-05-05 Sonography - gynecology
2025-05-05 2D transthoracic echocardiography
2025-05-03 CT - abdomen
2025-03-11 Sonography - gynecology
2024-12-17 Sonography - gynecology
2023-04-20 Papanicolaou test, Pap test
2023-04-20 Pathology - colorectal polyp
2023-04-20 Pathology - stomach biopsy
2023-04-20 Mammography
2023-04-20 Bone densitometry - hip
[MedRec]
2025-12-24 MultiTeam - Discharge preparation
2025-12-08 SOAP Hemato-Oncology
2025-11-10 ~ 2025-11-14 POMR Hemato-Oncology Yang MuJun
2025-09-15 ~ 2025-09-26 POMR Hemato-Oncology Yang MuJun
2025-08-07 SOAP Radiation Oncology Huang JingMin
2025-05-21 ~ 2025-06-17 POMR Hemato-Oncology Yang MuJun
2025-05-03 ~ 2025-05-16 POMR Cardiology Liu ZhiRen
2024-06-06, 2024-03-14, 2023-12-21, 2023-09-28, 2023-07-06, 2023-04-13, 2023-01-19, 2022-10-27, 2022-08-04, 2022-05-03, 2022-02-08, 2021-11-09, 2021-08-17 SOAP Cardiology Liu ZhiRen
2024-04-15, 2024-01-19, 2023-10-27, 2023-08-04, 2023-05-12, 2023-02-17 SOAP Metabolism and Endocrinology Hu YaHui
2021-05-25, 2021-03-02, 2020-12-08 SOAP Cardiology Liu ZhiRen
2020-11-26 ~ 2020-11-28 POMR Cardiology Liu ZhiRen
[consultation]
2025-12-23 Dermatology
2025-12-01 Pain Management
2025-12-01 Oral and Maxillofacial Surgery
2025-12-01 Dermatology
2025-11-12 Pain Management
2025-11-11 Oral and Maxillofacial Surgery
2025-11-10 Dermatology
2025-10-31 Orthopedics
2025-10-15 Anesthesia
2025-10-13 Dermatology
2025-09-23 Oral and Maxillofacial Surgery
2025-09-22 Radiation Oncology
2025-09-22 Neurosurgery
2025-09-19 Neurosurgery
2025-09-19 Rehabilitation
2025-09-16 Cardiology
2025-09-16 General and Gastroenterological Surgery
2025-09-15 Dermatology
2025-06-10 Metabolism and Endocrinology
2025-06-06 Diagnostic Radiology
2025-06-03 Radiation Oncology
2025-06-02 Hemato-Oncology
2025-05-29 Infectious Disease
2025-05-07 Hemato-Oncology
2025-05-07 Rheumatology and Immunology
2025-05-05 Obstetrics and Gynecology
2025-05-05 Gastroenterology
[surgical operation]
2025-11-17
2025-06-02
2025-05-22 10:00
2025-05-22 09:00
[immunochemotherapy]
2025-12-23 - pembrolizumab 100mg NS 90mL 30min
2025-11-10 - pembrolizumab 100mg NS 90mL 30min
2025-10-14 - pembrolizumab 100mg NS 90mL 30min + paclitaxel 175mg/m2 190mg NS 500mL 3hr + carboplatin AUC 5 320mg NS 250mL 30min (paclitaxel 70%, carboplatin 70%)
2025-09-23 - pembrolizumab 100mg NS 90mL 30min + paclitaxel 175mg/m2 190mg NS 500mL 3hr + carboplatin AUC 5 320mg NS 250mL 30min (paclitaxel 70%, carboplatin 70%)
2025-08-27 - pembrolizumab 100mg NS 90mL 30min + paclitaxel 175mg/m2 200mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 30min (paclitaxel 70%, carboplatin 70%)
2025-08-02 - pembrolizumab 100mg NS 90mL 30min + paclitaxel 175mg/m2 200mg NS 500mL 3hr + carboplatin AUC 5 360mg NS 250mL 30min (paclitaxel 70%, carboplatin 70%)
2025-07-10 - pembrolizumab 100mg NS 90mL 30min + paclitaxel 175mg/m2 165mg NS 500mL 3hr + carboplatin AUC 5 255mg NS 250mL 30min (paclitaxel 60%, carboplatin 60%; WBC 1.9K, ANC 1563)
2025-06-10 - pembrolizumab 100mg NS 90mL 30min + paclitaxel 175mg/m2 240mg NS 500mL 3hr + carboplatin AUC 5 470mg NS 250mL 30min (paclitaxel 80%, carboplatin 80%; first session, poor condition)
[medication]
Lenvima (lenvatinib 10mg)
Key insights/summary
Problem 1. Stage IV endometrioid carcinoma on systemic therapy (pembrolizumab-based; lenvatinib added) and post chemoradiotherapy
Problem 2. Severe postherpetic neuralgia and chronic zoster lesion of right leg with functional impairment
Problem 3. L5 compression fracture with abnormal marrow enhancement and right lower limb weakness; high fall risk
Problem 4. Anemia and thrombocytopenia in the setting of advanced cancer and therapy
Problem 5. Cancer-associated thrombosis history on chronic anticoagulation; procedural anticoagulation management
Problem 6. Type 2 diabetes mellitus on oral agents; inpatient safety in the context of renal function and systemic therapy
Problem 7. Chronic hepatitis B on antiviral prophylaxis; liver function monitoring during therapy
Problem 8. Hypertension and cardiovascular comorbidity during lenvatinib therapy
Problem 9. Polypharmacy and medication-safety review (renal function, sedation/falls, duplicates)
Key Insight / Summary
Problem 1. Metastatic endometrial carcinoma on triplet chemo-immunotherapy
Problem 2. Small bowel obstruction/ileus, improving
Problem 3. Anticoagulation for prior PE/DVT vs upper GI mucosal bleeding risk
Problem 4. Anemia and chemotherapy-related cytopenias
Problem 5. L5 compression fracture with abnormal marrow enhancement; neuropathy and radiculopathy
Problem 6. Renal function fluctuation with prior hydronephrosis; chemotherapy dosing safety
Problem 7. Diabetes with steroid/chemo-related hyperglycemia and variability
Problem 8. Electrolyte and nutrition balance
Problem 9. Infection/abscess surveillance and zoster history
Problem 10. Cardiovascular disease risk under oncologic therapy
Problem 11. Chronic HBV exposure on immunosuppressive therapy
Problem 12. Symptom control and supportive care
[GPT4o] (not for post)
This is a 64-year-old woman with FIGO 2023 stage IVB high-grade endometrioid carcinoma (pT3aN2acM1), post-staging surgery on 2025-05-22, with para-aortic and neck lymph node metastases. She is currently receiving pembrolizumab, paclitaxel, and carboplatin (latest on 2025-09-23). She was hospitalized on 2025-09-14 for small bowel obstruction and L5 compression fracture. Current concerns include worsening anemia, fluctuating renal function, severe neutrophilia with lymphopenia, possible metastatic spinal disease, steroid-induced or inflammatory hyperglycemia, and neuropathy. Overall clinical course is complex, involving immunochemotherapy, neurologic symptoms, and bowel obstruction recovery.
Problem 1. Advanced endometrial carcinoma with para-aortic and neck LN metastases
Problem 2. L5 compression fracture with suspected metastasis
Problem 3. Anemia
Problem 4. Leukocytosis with neutrophilia and lymphopenia
Problem 5. Acute kidney function fluctuation
Problem 6. Hyperglycemia under treatment
Problem 7. Neuropathy and right lower limb weakness
Problem 8. Post-operative bowel obstruction
Problem 9. Possible autoimmune association
[Subjective]
diarrhea symptoms persist
poor appetite and nutritional concern
HER2-targeted therapy inquiry
[Objective]
medications previously prescribed
pathology result
laboratory
[Assessment]
persistent low-grade diarrhea
suboptimal nutritional intake
HER2-targeted therapy not indicated
[Plan / Recommendation]
support symptom relief from diarrhea
optimize nutritional support
[anticoagulation with edoxaban while platelets remain >50 x10^3/uL]
Based on everything up to 2025-12-01, the previous statement that it is acceptable to continue anticoagulation with edoxaban while platelets remain >50 x10^3/uL is still supported for this simulated patient, and in fact the way Lixiana (edoxaban) has been used in the notes is quite consistent with guideline-based practice.
Key patient-specific rationales
50 x10^3/uL: full-dose anticoagulation generally acceptable in high-risk VTE patients.
Putting it together for this patient
Therefore:
If you want, next I can explicitly turn this into a problem-oriented A/B evaluation focusing on:
The patient is a 65-year-old woman with advanced endometrioid carcinoma, grade 3, stage IV (pT3aN2acM1) post staging surgery (2025-05-22). She has received pembrolizumab plus paclitaxel and carboplatin (cycles on 2025-06-10, 07-10, 08-02, 08-27) and pelvic radiotherapy (2025-06-23 to 2025-08-07).
Current admission (2025-08-26) was triggered by severe anemia (Hgb 7.5 g/dL). CBC reveals chronic anemia, thrombocytopenia, but WBC has improved compared to earlier nadirs. Renal and liver functions remain preserved. Persistent hyperglycemia is noted despite oral agents and frequent NovoRapid (insulin aspart) corrections. Urinalysis shows glycosuria and pyuria, suggesting uncontrolled diabetes and possible urinary tract infection. Vitals stable with ECOG PS 1.
The main issues are ongoing advanced malignancy management, hematologic toxicity (anemia, thrombocytopenia), infection risk, diabetes and glycemic control, anticoagulation in the context of thromboembolism history, and supportive care for nutrition and cachexia.
Problem 1. Advanced endometrioid carcinoma under systemic therapy
Problem 2. Anemia and thrombocytopenia
Problem 3. Hyperglycemia and diabetes control
Problem 4. Urinary tract infection
Problem 5. History of thromboembolism (not posted)
Problem 6. Supportive care: cachexia, nutrition, pain, infection prophylaxis (not posted)
[note on Problem 5] (not posted)
Yes. There is evidence-based support for continuing anticoagulation (edoxaban or other DOACs/LMWH) in cancer-associated thrombosis if platelets remain >50 x10^3/uL.
Rationales:
In summary:
[exam finding]
2025-12-24 CT - chest
2025-12-23, 2025-11-30, 2025-11-09, 2025-10-22, 2025-10-20, 2025-10-14 CXR
2025-10-27 CXR
2025-10-21 Sonography - chest
2025-10-20 PD-L1 (SP142) assay (Ventana)
2025-10-17 Pathology
2025-10-17 MRI - brain
2025-10-16 PET
2025-10-16 Pathology
2025-10-15 Tc-99m MDP bone scan
2025-10-15 Esophagogastroduodenoscopy, EGD
2025-10-14 Pathology - lung transbronchial biopsy
2025-10-12 CT - abdomen
2025-10-12 ECG
2025-10-02 MRI - L-spine
[MedRec]
2025-11-17 SOAP Hemato-Oncology Yang MuJun
2025-10-12 ~ 2025-10-27 POMR Hemato-Oncology Yang MuJun
[consultation]
2025-12-24 Oral and Maxillofacial Surgery
[radiotherapy]
[chemotherapy]
Key insight/summary
Problem 1. Extensive-stage small cell lung carcinoma on first-line chemoimmunotherapy
Problem 2. Anemia with prior gastrointestinal bleeding and transfusion requirement
Problem 3. Electrolyte instability: recurrent hypokalemia and hypomagnesemia
Problem 4. Pleural effusion and pulmonary disease burden with infection surveillance needs
Problem 5. Hepatitis B reactivation risk under immunochemotherapy
Problem 6. Supportive care polypharmacy: pain control, constipation, and CNS depressant risk
Problem 7. Vascular access: Port-A management during ongoing chemotherapy
Key insights / summary
Problem 1. Extensive-stage small cell lung carcinoma on chemoimmunotherapy
Problem 2. Chronic anemia with ongoing GI bleeding and cancer-related causes
Problem 3. Recurrent hypokalemia and hypomagnesemia
Problem 4. Infection risk and inflammation with Port-A catheter and periodontitis
Problem 5. HBV reactivation risk under chemoimmunotherapy
Problem 6. Bone metastases, pathologic fracture risk, and pain control
Problem 7. Cardiovascular comorbidities and treatment tolerance
Problem 8. Nutritional status and functional performance
Problem 9. Symptom control: nausea, constipation, hemorrhoids/anal bleeding and gastric protection
Overall, the patient is on an appropriate, guideline-concordant path for extensive-stage SCLC with good organ reserve. The dominant near-term priorities are to complete and assess first-line chemoimmunotherapy, stabilize anemia and electrolytes, manage infection risk and HBV reactivation, and continue proactive symptom and skeletal event prevention.
[Potential Medication Issues]
Problem 1. Chemoimmunotherapy regimen (Atezolizumab/Carboplatin/Etoposide)
Problem 2. Anemia management and RBC transfusion strategy
Problem 3. Electrolyte replacement (hypokalemia and hypomagnesemia) with interacting drugs
Problem 4. Opioid and analgesic regimen (morphine + tramadol/acetaminophen)
Problem 5. Tranexamic acid for hemorrhoidal and GI bleeding in a prothrombotic cancer patient
Problem 6. HBV prophylaxis (Vemlidy) under chemoimmunotherapy
Problem 7. Bone-modifying therapy and dental issues
Problem 8. Anti-hypertensive and potassium-sparing regimen during dynamic fluid/electrolyte changes
Problem 9. Antiemetic regimen and drug–drug interaction considerations
Problem 10. Radiotherapy history and future planning
Overall, current medications and treatments are broadly appropriate but require ongoing fine-tuning around anemia, electrolytes, opioid use, antifibrinolytic therapy, HBV prophylaxis, bone protection and cardio-metabolic risks. Regular structured medication reviews and close lab/vital monitoring will be key to maintaining safety while preserving the intended benefits of cancer-directed therapy.
[exam finding]
2025-11-09 16:50 ECG
2025-11-09 14:38 ECG
2025-10-17 22:48 ECG
2025-10-17 16:55 ECG
2025-09-23 10:28 ECG
2025-09-23 2D transthoracic echocardiography
2025-09-22 Flow Volume Chart
2025-09-20 Merchant’s view of right knee
2025-09-11 CT - abdomen
2025-03-25 ECG
2025-03-04 Sonography - abdomen
2025-02-14 Pathology - colorectal polyp
2025-02-13 Sigmoidoscopy
2025-02-11 Pathology - thrombus or embolus
2024-11-19 CXR
2024-11-07 Sigmoidoscopy
2024-11-06 MRI - pelvis
2024-11-05 PET
2024-11-01 CT - abdomen
2024-10-17 Patho - colon biopsy
2024-10-17 Esophagogastroduodenoscopy, EGD
2024-10-17 Colonoscopy
2024-09-19 SONO - abdomen
2024-04-20 Microsonography
2024-01-09 SONO - abdomen
2023-12-07 CT - abdomen
2023-12-07 ECG
2023-12-07 KUB
2023-12-07 CXR
2023-11-23 Spirometry
2023-09-16 L-spine AP + Lat (including sacrum)
2023-07-20 2D transthoracic echocardiography
2023-07-18 Myocardial Perfusion SPECT with persantin
2023-04-17 Sigmoidoscopy
2023-04-11 Anoscopy
2023-08-07, 2022-08-23 SONO - abdomen
2022-07-12 Holter 24hr ECG
2021-03-05 CT - abdomen
2020-11-24 Myocardial perfusion SPECT with persantin
2020-09-10 Patho - colon biopsy
2020-05-19 2D transthoracic echocardiography
2020-05-12 Spirometry
2020-05-05 SONO - abdomen
2019-08-22 Surgical pathology Level V
2019-05-02 Surgical pathology Level IV
2019-03-12 CT - abdomen
[MedRec]
2025-11-18 SOAP General and Gastroenterological Surgery Wu Chaoqun
2025-10-11 SOAP Cardiology Zhan ShiRong
2025-09-21 ~ 2025-09-24 POMR Colorectal Surgery Xiao GuangHong
2025-08-26 SOAP General and Gastroenterological Surgery Li ChaoShu
2025-08-12 SOAP Ophthalmology Yang YunXiang
2025-06-27 MultiTeam - Social services
2025-06-10 ~ 2025-06-14 POMR Hemato-Oncology Xia HeXiong
2025-03-11 ~ 2025-03-16 POMR Hemato-Oncology Xia HeXiong
2024-11-24 ~ 2024-11-30 POMR Hemato-Oncology Xia HeXiong
2024-11-12 SOAP Radiation Oncology Wang YuNong
2024-11-07 SOAP Hemato-Oncology Xia HeXiong
2024-08-15 SOAP Hemato-Oncology Xia HeXiong
2021-02-08 MultiTeam - Social services
[consultation]
2025-12-23 Nephrology
2025-02-06 Nephrology
2025-01-02 Nephrology
2024-11-25 Nephrology
2023-12-08 Nephrology
2021-02-06 Nephrology
[surgical operation]
2025-02-10
2024-11-19
2019-08-22
2018-01-10
2018-01-08
[radiotherapy]
[chemotherapy]
Key insights / summary
Problem 1. Rectal adenocarcinoma after TNT with tumor regrowth and ongoing hematochezia; restaging need and limited operability
Problem 2. ESRD on hemodialysis with contrast-exposure coordination and volume/electrolyte management
Problem 3. Chronic anemia with episodic exacerbation from rectal bleeding and ESRD
Problem 4. Thrombocytopenia and bleeding diathesis risk in the setting of portal hypertension/splenomegaly and chronic disease
Problem 5. Post liver transplantation status with immunosuppression and HBV prophylaxis; portal hypertension physiology
Problem 6. Cardiovascular disease: ischemic heart disease, atrial arrhythmias, valvular regurgitation, and anticoagulation constraints due to bleeding
Problem 7. COPD / obstructive ventilatory impairment and peri-procedural respiratory risk
Problem 8. Frailty, malnutrition risk, and functional/social vulnerability affecting treatment feasibility
[Medication- and treatment-related problems to flag] on 2025-12-24
Antifibrinolytic use in a patient with thrombotic/arrhythmic risk
Hepatitis B antiviral dosing appears potentially subtherapeutic for ESRD on hemodialysis
Tacrolimus exposure may be unstable due to interacting drugs and adsorption/separation issues
Cimetidine safety in ESRD and polypharmacy
Magnesium-containing therapy in ESRD
Phosphate binder and electrolyte monitoring gaps
Blood pressure and antianginal regimen around dialysis and planned contrast CT
Contrast-enhanced CT in ESRD on hemodialysis: logistics and safety checks
Anemia management strategy: ESA vs transfusion in ongoing bleeding
The patient is a post-liver transplant recipient with rectal cancer status post CCRT and ongoing hemodialysis-dependent ESRD. He is receiving FOLFOX chemotherapy and immunosuppression with Prograf (tacrolimus). Over the last two months, the patient has experienced progressive anemia, persistent thrombocytopenia, and worsening renal function. Liver function remains biochemically stable, but there is a concern for subtherapeutic tacrolimus levels. The patient tolerates chemotherapy well without major GI or infectious complications.
Problem 1. Progressive Anemia
Problem 2. Renal Dysfunction (ESRD on Hemodialysis)
Problem 3. Liver Function & Tacrolimus Monitoring (Post-transplant liver)
Problem 4. Chemotherapy for Rectal Cancer
[Anemia]
The patient has recent evidence of anemia with a hemoglobin (Hgb) level of 6.8 g/dL on 2025-02-06, down from 9.5 g/dL on 2025-01-16, accompanied by macrocytosis (MCV 101.5 fL). This anemia occurs in the context of advanced malignancy, recent chemotherapy with FOLFOX (2025-02-07), chronic kidney disease requiring hemodialysis (HD), and a history of liver transplantation under Prograf (tacrolimus). Anemia management must consider underlying causes such as chemotherapy effects, CKD-related anemia, and potential deficiencies.
Step 1: Objective Findings
Step 2: Assessment
Step 3: Recommendations
[Patient Summary]
This is a 65-year-old male with a complex medical history including:
[Anemia Assessment]
Current Status:
Etiology:
Management Recommendations:
[Iron Status Assessment]
The lab results show iron levels and related parameters from 2024-09-14, which provide info for the patient’s iron status:
Iron Studies (2024-09-14):
Interpretation:
Conclusion:
Management Recommendations:
[Liver Function Test]
Evaluation of Liver Function and Trends in the Last 3 Months:
Key Liver Function Indicators:
Trend Analysis:
Conclusion:
[Comments on Tacrolimus Levels]
Observed Trends and Levels
Integration with the Current Context
[Transplanted Liver Function Assessment] (not posted)
Clinical Context
Laboratory Trends
Imaging Findings
Integration of Tacrolimus Levels
Synthesis
Next Steps
[lab data]
2025-12-24 Bone Marrow Chromosome Analysis
[exam finding]
2025-12-11 2D transthoracic echocardiography
2025-12-10 Pathology - bone marrow biopsy
2025-12-10 Sonography - abdomen
2025-12-09 Flow Volume Chart
[MedRec]
2025-12-09 ~ 2025-12-22 POMR Hemato-Oncology Liu YiSheng
2020-07-10 ~ 2020-07-17 POMR Obstetrics and Gynecology Chen YiLing
[Subjective]
2025-12-24 pharmacist follow-up
Symptoms prior to index admission
[Objective]
Hematologic malignancy workup
CBC trends demonstrating persistent pancytopenia - 2025-12-08: WBC 2.32 x10^3/uL, Hgb 4.9 g/dL, Plt 27 x10^3/uL (CBC 2025-12-08) - 2025-12-10: WBC 1.51 x10^3/uL, Hgb 6.8 g/dL, Plt 125 x10^3/uL (CBC 2025-12-10) - 2025-12-12: WBC 1.55 x10^3/uL, Hgb 9.5 g/dL, Plt 90 x10^3/uL (CBC 2025-12-12) - 2025-12-15: WBC 1.67 x10^3/uL, Hgb 9.0 g/dL, Plt 36 x10^3/uL (CBC 2025-12-15) - 2025-12-17: WBC 1.73 x10^3/uL, Hgb 8.4 g/dL, Plt 92 x10^3/uL (CBC 2025-12-17) - 2025-12-19: WBC 1.90 x10^3/uL, Hgb 7.9 g/dL, Plt 56 x10^3/uL (CBC 2025-12-19) - 2025-12-22: WBC 2.69 x10^3/uL, Hgb 9.2 g/dL, Plt 28 x10^3/uL (CBC 2025-12-22)
Chemistry and renal/hepatic function
Hepatitis B status
Care trajectory
[Assessment]
Acute myeloid leukemia with t(8;21) and ongoing pancytopenia
Bleeding risk from thrombocytopenia
Infection risk from leukopenia and likely neutropenia
Hepatitis B reactivation risk with anticipated AML therapy
Care continuity and safety after discharge against medical advice
[Plan / Recommendation]
Patient and caregiver education
Medication-related actions for improvement (pharmacist-led)
Communication and transitions of care
Follow-up recommendation
Key insights/summary
Problem 1. Acute myeloid leukemia with t(8;21) (core-binding factor AML) with diagnostic discordance across morphology/IHC/flow
Problem 2. Severe cytopenias (anemia, thrombocytopenia, leukopenia) with transfusion dependence and bleeding/infection risk
Problem 3. Chronic hepatitis B infection with very low viremia and impending intensive chemotherapy-associated reactivation risk
Problem 4. Respiratory symptoms at presentation with uncertain etiology in the context of severe anemia and immunocompromise risk
Problem 5. Mild electrolyte abnormalities and renal function considerations for chemotherapy planning
[GPT 5.2 differential diagnosis based on labs and pathology in descending possibility]
Acute myeloid leukemia (AML), likely non-APL
AML evolving from an underlying myelodysplastic neoplasm (MDS/AML spectrum) or AML with myelodysplasia-related changes (provisional differential; needs cytogenetics/NGS + morphology details)
Severe bone marrow failure syndrome manifesting as pancytopenia (secondary to malignant infiltration rather than aplastic anemia)
Chronic hepatitis B infection (HBV), currently serologically active (infection status and phase need HBV DNA, HBeAg/anti-HBe)
High risk for infection / neutropenia-associated infection (currently no clear evidence of systemic infection in the provided data)
Bleeding risk due to thrombocytopenia (with possible secondary consumptive process to be ruled out)
Severe anemia with macrocytosis pattern (primary marrow production failure favored; nutritional deficiency/hemolysis/bleeding less supported by current data)
Mild hypokalemia (intermittent)
Notes on key discriminators to refine the top differentials (if available later)
[the possibilty of myelodysplasitc syndrome with excessive blasts]
It is a reasonable consideration early in the workup, but with the data you provided, it is currently less likely than AML.
Bottom line: MDS-EB is plausible as an antecedent or underlying biology, but the current dataset (marrow blasts 33.5% on 2025-12-11) is most consistent with AML at presentation rather than MDS-EB.
[exam finding]
2025-11-21 CT - abdomen
2025-11-19 Sonography - abdomen
2025-11-18 Pathology - liver biopsy needle/wedge
2025-11-17 EsophagoGastroDuodenoscopy, EGD
2025-11-14 CT - abdomen
2025-11-14 2D transthoracic echocardiography
2025-11-12 Tc-99m MDP bone scan
2025-11-05 CXR
2025-10-14 Sonography - abdomen
2025-09-05 CT - abdomen
2025-09-04 CXR
2025-08-13 Pathology - liver biopsy needle/wedge
2025-08-09 CT - abdomen
2025-08-08 CXR
2025-07-14 Sonography - abdomen
2025-06-24 Sonography - thyroid
2025-05-15 MRI - L-spine
2025-04-23 Esophagogastroduodenoscopy, EGD
2025-04-12 CT - abdomen
2025-03-11 Embolization (TAE) - abdomen for tumor
2025-02-11 CT - abdomen
2025-01-14 Embolization (TAE) - abdomen for tumor
2024-12-11 Embolization (TAE) - abdomen for tumor
2024-12-10 CT - abdomen
2024-11-06 Sonography - abdomen
2024-11-04 ECG
2024-10-07 CT - abdomen
2024-08-15 Pathology - liver biopsy needle/wedge
2024-08-05 CT - abdomen
2024-08-05 Esophagogastroduodenoscopy, EGD
2024-08-01 Sonography - abdomen
[MedRec]
2025-12-08 ~ 2025-12-15 POMR Hemato-Oncology Xia HeXiong
2025-11-27 ~ 2025-11-29 POMR Hemato-Oncology Xia HeXiong
2025-11-12 SOAP Hemato-Oncology Xia HeXiong
2025-10-12 ~ 2025-10-18 POMR Gastroenterology Gong ZiXiang
2025-09-06 ~ 2025-09-19 POMR Hemato-Oncology Xia HeXiong
2025-07-10 ~ 2025-07-14 POMR Gastroenterology Zhan WeiYu
2024-11-04 ~ 2024-11-12 POMR Gastroenterology Zhan WeiYu
2024-08-14 ~ 2024-08-16 POMR Gastroenterology Zhan WeiYu
[consultation]
2025-08-11 Hemato-Oncology
2025-06-13 Metabolism and Endocrinology
2025-06-12 Dermatology
2025-05-15 Radiation Oncology
2025-05-15 Dermatology
[surgical operation]
2025-10-27
[radiotherapy]
2025-09-08 ~ 2025-10-03 - 4000cGy/20 fractions (15MV photon) of the right liver tumor area.
2025-05-20 ~ 2025-06-03 - 3000cGy/10 fractions (15 MV photon) of the T11 ~ L1 area.
[immunochemotherapy]
2025-12-24 - MTX-GPC3-303 0.1mg/Kg 7.1mg 7.9mL NS 50mL 57.9min + NS 10mL 10min + NS 500mL
2025-12-11 - MTX-GPC3-303 0.1mg/Kg 7.1mg 7.9mL NS 50mL 57.9min + NS 10mL 10min + NS 500mL
2025-12-02 - MTX-GPC3-303 0.03mg/Kg 2.1mg 2.3mL NS 50mL 52.3min + NS 10mL 10min + NS 500mL
2025-11-28 - MTX-GPC3-303 0.015mg/Kg 1.1mg 1.2mL NS 50mL 51.2min + NS 10mL 10min + NS 500mL
2025-07-11 - Imfinzi (durvalumab) 1500mg NS 250mL 1hr
2025-06-12 - Imfinzi (durvalumab) 1500mg NS 250mL 1hr
2025-05-14 - Imjudo (tremelimumab) 300mg NS 150mL 1hr + Imfinzi (durvalumab) 1500mg NS 250mL 1hr (After infusion of Imjudo for 60 minutes, the patient was observed for 60 minutes, and Imfinzi was infused separately on the same day)
2025-04-23 ~ 2025-05-10 - Lenvima (levatinib 10mg) 1# QD OPD
2025-03-10 - doxorubicin 10mg for TACE IPD
2025-01-13 - doxorubicin 10mg for TACE IPD
2024-12-11 - doxorubicin 10mg for TACE IPD
2024-12-09 - Opdivo (nivolumab) 100mg NS 100mL 1hr
2024-11-11 - Opdivo (nivolumab) 100mg NS 100mL 1hr
2024-08-27 ~ 2024-10-05 - Lenvima (levatinib 10mg) 1# QD OPD
2024-08-23 ~ 2025-11-18 ongoing - Vemlidy (tenofovir alafenamide 25mg) 1# QD
Key insights/summary
Problem 1. Advanced progressive hepatocellular carcinoma with macrovascular invasion and metastatic disease (liver, portal vein, adrenal, lung, bone)
Problem 2. Portal hypertension and upper GI mucosal disease (portal hypertensive gastropathy, reflux esophagitis, prior varices), with bleeding risk amplified by coagulopathy
Problem 3. Coagulopathy and thrombocytopenia (mixed hepatic synthetic dysfunction, inflammation, hypersplenism), with procedure and bleeding implications
Problem 4. Anemia with reticulocytosis, intermittent severe drops, and likely multifactorial drivers
Problem 5. Systemic inflammation/CRS risk during MTX-GPC3-303 trial therapy; infection risk may be masked by IL-6 blockade
Problem 6. Hepatic function, cholestatic injury pattern, and HBV carrier status on antiviral prophylaxis
Problem 7. Bone metastasis at T12 with prior radiotherapy; fracture risk and pain management needs
Problem 8. Cardiopulmonary status and metastatic lung disease; current oxygenation is stable
Problem 9. Electrolytes, renal function, and acid-base status: currently stable but vulnerable to diuretics, poor intake, and systemic inflammation
Problem 10. Endocrine: evolving thyroid dysfunction and possible adrenal axis suppression
Problem 11. Central venous access (port-A) and line-associated risks
Problem 12. Symptom management: anorexia/cachexia, nausea, insomnia, and medication burden
Key insights / summary
Problem 1. Progressive advanced hepatocellular carcinoma with macrovascular invasion and extrahepatic metastases; evaluation for MTX-GPC3-303 trial
Problem 2. Portal hypertension with portal vein thrombosis, portal hypertensive gastropathy, varices, splenomegaly, and ascites
Problem 3. Bone metastasis with T12 vertebral destruction and prior radiotherapy
Problem 4. HBV-related cirrhosis with low-level HBV viremia under antiviral prophylaxis
Problem 5. Immune-related thyroid dysfunction evolving to hypothyroidism
Problem 6. Mild normocytic anemia in the setting of chronic liver disease, malignancy, and portal hypertensive gastropathy
Problem 7. Volume status management, albumin infusion, and diuretic therapy
Problem 8. Immunotherapy and radiation toxicities, skin issues, and readiness for further intensive treatment
Potential Medication Issues
[nonselective beta-blocker (NSBB) prophylaxis for variceal bleeding]
Here are several academic published articles and systematic reviews focused on nonselective beta-blocker (NSBB) prophylaxis for variceal bleeding:
Key Academic Articles
Representative Systematic Review Reference
Representative Guidelines Summary
Additional Recent Clinical Insights
Ref:
[exam finding]
2025-12-10 CXR
2025-12-08 Pathology - lung wedge biopsy
2025-12-08 ECG
2025-12-07 CXR
2025-12-05 Flow Volume Chart
2025-11-26 Pathology - lung transbrochial biopsy
2025-10-20 CT - abdomen
2025-07-07 CT - chest
2025-07-02 2D transthoracic echocardiography
2025-07-01 ECG
2025-07-01 Pathology - cholecystectomy for gallbladder cancer
PATHOLOGIC DIAGNOSIS:
MACROSCOPIC EXAMINATION
MICROSCOPIC EXAMINATION
2025-06-27 Bronchodilator Test, BDT
2025-06-27 2D transthoracic echocardiography
2025-06-26 Esophagogastroduodenoscopy, EGD
2025-06-25 Sonography - abdomen
[MedRec]
2025-12-19 SOAP Chest Medicine Yang MeiZhen
2025-12-07 POMR Thoracic Surgery Xie MinXiao
2025-11-25 ~ 2025-11-27 POMR Hemato-Oncology Xia HeXiong
2025-09-17 SOAP Hemato-Oncology Xia HeXiong
2025-06-24 ~ 2025-08-01 POMR General and Gastroenterological Surgery Wu ChaoQun
2021-02-17 ~ 2021-02-24 POMR General and Gastroenterological Surgery Wu ChaoQun
[consultation]
2025-12-08 Infectious Disease
2025-07-10 Gastroenterology
[surgical operation]
2025-12-08
2025-08-18
2025-06-30
2021-02-22
[chemotherapy]
[Subjective]
2025-12-24 follow-up
[Objective]
Pulmonary cryptococcosis workup and pathology
Oncologic background and chemotherapy exposure
Recent relevant physiology and baseline labs available in record
[Assessment]
Pulmonary cryptococcosis / cryptococcoma in the context of malignancy and recent chemotherapy exposure
Medication safety / interaction considerations relevant to current regimen and anticipated chemotherapy resumption
Symptom management request
[Plan / Recommendation]
Antifungal optimization and infection control prior to chemotherapy resumption
Medication monitoring and safety actions
Symptom-directed supportive care
Care process improvements for next contact
Key insights/summary
Problem 1. Gallbladder carcinoma, pT3N2, Stage IVB, postoperative state and adjuvant systemic therapy planning
Problem 2. Pulmonary cryptococcosis (cryptococcoma) in the setting of chemotherapy and recent VATS wedge resections
Problem 3. Chemotherapy-related toxicity risks: myelosuppression, infection vulnerability, nephrotoxicity, and electrolyte wasting
Problem 4. Cardiovascular disease and conduction abnormalities with peri-treatment implications
Problem 5. Chronic viral hepatitis serology, antiviral prophylaxis during chemotherapy, and liver function preservation
Problem 6. Pulmonary function impairment and postoperative pulmonary status
Problem 7. Postoperative RUQ fluid collection and splenomegaly after gallbladder cancer surgery
Problem 8. Medication regimen safety, appropriateness, and reconciliation across oncology, infection, and comorbidity care
[Clinical Counseling Brief (pharmacist internal use)] for 2025-12-24
High-Priority Medication Precautions
Vigilant Monitoring for Adverse Reactions (ADRs)
Necessary Follow-up Lab Tests & Exams (patient-specific)
Diagnostic & Therapeutic Clarification (prescribing gaps and suggested questions)
[exam finding] (not completed)
2025-12-20 CXR
2025-12-18 CXR
2025-12-08 PET
2025-12-08 CXR
2025-12-04 Tc-99m MDP bone scan
2025-12-04 2D transthoracic echocardiography
2025-12-03 MRI - brain
2025-12-03 Sonography - abdomen
2025-12-03 Sonography - nephrology
2025-12-02 CXR
2025-11-25 ECG
2025-11-25 CT - abdomen
2025-11-25 CXR
2025-11-24 Pathology - colon biopsy
2025-11-21 Colonoscopy
2025-11-14 CXR
2025-10-04 ECG
2025-09-09 ECG
2025-09-09 CT - abdomen
2025-07-21 CT - abdomen
2025-04-22 CT - chest
2025-01-06 Tc-99m MDP bone scan with SPECT
2025-01-03 PET
2024-12-26 CT - abdomen
2024-11-11 CXR
2024-10-28 MRI - pelvis
2024-10-28 CT - brain
2024-09-06 CT - chest
2024-01-09 CT - chest
2023-11-01 Pathology - lung total/lobe/segemental
2023-10-31 ECG
2023-09-04 CT - chest
2023-05-25 CT
2023-05-10 Pathology - thyroid total/lobe
2023-05-08 ECG
2023-04-14 All RAS & BRAF mutation test
2023-04-14 Pathology - gall bladder
2023-04-14 Pathology - liver partial resection
2023-04-14 Pathology - colon segemental resection for tumor
2023-03-28 Sonography - thyroid gland
2023-03-21 PET
2023-03-17 CT - abdomen
2023-03-17 ECG
2023-03-13 Pathology - colon biopsy
2023-03-13 Pathology - colon biopsy
2023-03-11 Colonoscopy
2023-03-11 Esophagogastroduodenoscopy, EGD
2023-02-03 Pap’s Smear
2023-02-02 Sonography - gynecology
[MedRec]
2025-12-23 MultiTeam - Palliative care
2023-05-08 ~ 2023-05-11 POMR General and Gastroenterological Surgery
2023-04-11 ~ 2023-04-20 POMR Colorectal Surgery
2023-03-31 SOAP Colorectal Surgery
[consultation]
2025-12-22 Family Medicine
2025-12-05 Oral and Maxillofacial Surgery
2025-12-04 Radiation Oncology
2025-12-03 Nephrology
2025-11-27 Colorectal Surgery
[chemotherapy]
Lonsurf (trifluridine 20mg, tipiracil 9.42mg)
Baraclude (entecavir 0.5mg)
Eltroxin (levothyroxine 50mcg)
Xeloda (capecitabine 500mg)
Key insight/summary
Problem 1. Advanced metastatic colorectal cancer with multi-organ involvement and palliative goals of care
Problem 2. Gastrointestinal bleeding (coffee-ground emesis and ongoing hematochezia) with coagulopathy and thrombocytopenia
Problem 3. Hepatic failure from diffuse liver metastases with hyperbilirubinemia and cholestatic pattern
Problem 4. Infection concern and leukocytosis (possible UTI/other source) in an immunocompromised advanced cancer patient
Problem 5. Acute kidney injury and electrolyte/acid-base disorders (hyperkalemia, hyponatremia history, metabolic acidosis)
Problem 6. Volume overload with severe bilateral lower limb edema, ascites, and hypo-oncotic physiology
Problem 7. Pain, nausea/vomiting, constipation, and overall symptom control near end of life
Problem 8. Cardiopulmonary status with extensive lung metastases and underlying cardiovascular disease
[exam findings]
2025-10-20 ECG
2025-10-13 CT - chest
2025-07-04 MRI - L-spine
2025-06-18 Tc-99m MDP bone scan
2025-06-05 CT - abdomen
2025-02-06 Sonography - abdomen
2025-02-05 CXR
2024-11-13 CT - abdomen
2024-07-11 CT - abdomen
2024-03-16 CT - abdomen
2023-12-06 ~ 2023-12-11 ECG
2023-11-10 Pathology - colon resection (non-tumor) (Y1)
2023-11-09 PET scan
2023-11-04 CT - abdomen
2023-09-28 Colonoscopy
2023-09-28 SONO - abdomen
2022-09-29 SONO - abdomen
2021-10-05 CT - abdomen
2021-10-05 Colonoscopy
2020-11-10 Sonography - abdomen
2020-05-13 CT - abdomen
2019-07-06 MRI - L-spine
2019-06-24 L-spine flex. & ext. (including sacrum)
2019-06-03 Phleborheograph, PRG, perivasculary Doppler flowmetry
2019-06-03 Antegrade Venography
2019-05-16 CT - abdomen
2017-10-20 Pathology
2017-10-15 CT - abdomen
[MedRec]
2025-11-23 ~ 2025-11-27 POMR Hemato-Oncology He JingLiang
2023-12-10 ~ 2023-12-13 POMR Hemato-Oncology He JingLiang
2017-10-16 ~ 2017-10-28 POMR Colorectal Surgery Xiao GuangHong
[consultation]
2025-11-25 Dermatology
[surgical operation]
2023-12-08
2019-06-06
2017-10-26
2017-10-20
[radiotherapy]
[chemotherapy]
Key Insights/Summary
Problem 1. Metastatic sigmoid colon adenocarcinoma on Vectibix (panitumumab) + FOLFIRI
Problem 2. Pulmonary metastases and thoracic nodal findings
Problem 3. Panitumumab-associated acneiform eruption and skin care (EGFR inhibitor toxicity)
Problem 4. Gastrointestinal toxicity risk from FOLFIRI and current supportive antiemesis/diarrhea plan
Problem 5. Renal/urinary tract considerations: mild left hydroureter and hydronephrosis, pelvic recurrence history
Problem 6. Cardiovascular status: sinus bradycardia and borderline ECG findings
Problem 7. Electrolytes and metabolic status: borderline hypokalemia risk during chemotherapy
Problem 8. Musculoskeletal/osseous findings: degenerative changes and indeterminate C-spine uptake on bone scan
Problem 9. Hepatic steatosis with preserved liver function
The lab results obtained on 2024-05-01, were largely unremarkable, and the patient’s ECOG performance status of 1 indicated no apparent reason to withhold FOLFOX therapy.
The lab results on 2024-01-07 were grossly normal and ECOG PS 1, no obvious contraindication to the administration of FOLFOX.
[exam finding]
2025-12-19, 2025-12-01 CXR
2025-11-24 Body fluid cytology
2025-11-24 Sonography - chest
2025-11-24 Sonography - abdomen
2025-11-21 CXR
2025-11-21 CT - chest
2025-11-19 Pathology - colorectal polyp
2025-11-18 Esophagogastroduodenoscopy, EGD
2025-11-17 Body fluid cytology
2025-11-14 CXR
2025-11-14 ECG
2025-11-14 CT - abdomen
2025-11-14 Sonography - gynecology
2025-11-14 Sonography - abdomen
2020-01-31 Bone densitometry - hip
[MedRec]
2025-12-19 ~ 2025-12-21 POMR Hemato-Oncology Yang MuJun
2025-11-16 ~ 2025-11-26 POMR Hemato-Oncology Yang MuJun
[surgical operation]
2025-11-21
2025-11-17
[chemotherapy]
2025-10-27 CT - chest
2025-10-27 2D transthoracic echocardiography
2025-10-08 PET
2025-09-30 Pathology - breast biopsy (no need margin)
2025-09-29 Sonography - breast
2023-07-30 C-spine AP + Lat
2021-03-18 Sonography - nephrology
2020-10-15 Somatosensory Evoked Potential, SSEP
2020-10-15 Neurosonography
2017-09-14 2D transthoracic echocardiography
2017-09-14 Bruce Treadmill exercise test
[exam finding]
2025-12-21 KUB
2025-12-21 CXR
2025-12-12 Pathology - colorectal polyp
2025-12-11 Colonoscopy
2025-11-24 CXR
2025-11-22 09:25 ECG
2025-11-21 16:13
2025-11-21 Cardiac Catheterization
2025-11-20 CXR
2025-11-18 ECG
2025-11-18 07:39 ECG
2025-11-17 CT - abdomen
2025-11-04 Pathology
2025-11-04 Colonoscopy
2025-10-19 KUB
2025-10-09 2D transthoracic echocardiography
2025-06-11 2D transthoracic echocardiography
2025-01-13 CXR
2025-01-10 Cardiac Catheterization
2025-01-09 CXR
2025-01-07 06:38 ECG
2025-01-06 18:13 ECG
2025-01-06 14:54 CXR
2025-01-06 14:46 ECG
2024-10-14 Cardiac Catheterization
2024-10-14 01:03 CXR
2024-10-14 00:55 ECG
2024-10-14 2D transthoracic echocardiography
2022-04-12 2D transthoracic echocardiography
[MedRec]
2025-11-19 ~ 2025-11-25 POMR Cardiology Liu ZhiRen
2025-10-24 SOAP Cardiology Liu ZhiRen
2025-01-07 ~ 2025-01-13 POMR Cardiology Liu ZhiRen
2024-10-14 ~ 2024-10-18 POMR Cardiology Xie JianAn
2017-02-20 ~ 2017-02-22 POMR Urology
2013-04-09 ~ 2013-04-15 POMR Cardiology Liu ZhiRen
[consultation]
2025-11-21 Hemato-Oncology
2025-11-19 Gastroenterology
2025-11-18 Cardiology
2024-10-14 Rehabiliation
2024-10-14 Cardiology
[surgical operation]
2017-02-21
Key Insights/Summary
Problem 1. Metastatic transverse colon malignancy with near obstruction and uncertain histologic certainty on recent biopsy
Problem 2. Cancer-associated symptom burden and tumor marker trend monitoring
Problem 3. Severe coronary artery disease with recent PCI and need for antithrombotic coordination
Problem 4. Heart failure with reduced ejection fraction and ischemic cardiomyopathy
Problem 5. Anemia, likely iron deficiency, with ongoing oncologic and cardiovascular implications
Problem 6. Renal function impairment and nephroprotection during chemotherapy planning
Problem 7. Pulmonary nodules, left upper lobe opacity, and pleural effusions: staging, differential, and symptom risk
Problem 8. Elevated D-dimer and cancer-associated thrombosis risk
Problem 9. Type 2 diabetes mellitus and peri-treatment glycemic safety
Problem 10. Medication reconciliation and supportive care readiness for chemotherapy initiation
[Mirapex 0.375 mg prolonged-release (pramipexole ER) tube-feeding for vascular parkinsonism]
Clinical context
Assessment and rationale
Plan and recommendations
[Leukeran (chlorambucil) tube feeding]
Medication and indication context
Assessment and rationale
Recommendation
Bottom line for gastric NG - Mirapex ER: do not tube; convert to pramipexole IR and administer with standard NG flush technique. :contentReferenceoaicite:3 - Chlorambucil tablet: do not crush/split/tube. If NG is mandatory, only consider an appropriate liquid prepared/handled under hazardous-drug controls. :contentReferenceoaicite:4
[exam findings]
2025-12-18 ECG
2025-11-25 CXR
2025-10-20 Pathology - muscle biopsy
2025-10-07 Tc-99m MDP bone scan
2025-10-03 ECG
2025-10-03 2D transthoracic echocardiography
2025-10-01 Papanicolaou test, Pap smear
2025-09-30 Pelvis & Bilat Hip Lat
2025-09-30 CXR
2025-09-30 ECG
2025-09-30 Sonography - gynecology
2025-09-22 MRI - upper abdomen
2025-09-22 CT - chest
2025-08-18 MRI - pelvis
2025-06-09 CXR
2025-06-09 ECG
2025-06-05 Sonography - nephrology
2025-05-13 Sonography - thyroid gland
2025-04-26 MRI - C-spine
2025-03-20 Nerve Conduction Velocity, NCV
2025-01-17 Sonography - soft tissue
2025-01-16 Sonography - abodmen
2025-01-09 2D transthoracic echocardiography
2025-01-08 CT - lower limbs
2025-01-08 ECG
2024-10-24 Pathology - pleural/pericardial biopsy
2024-10-15 2D transthoracic echocardiography
2024-10-09 Pathology - pleural/pericardial biopsy
2024-10-08 CTA - chest
2024-10-07 Pathology - heart valve
2024-10-04 Transesophageal echocardiography, TEE
2024-10-01 Cardiac Catheterization
2024-10-01 ECG
2024-09-09 CTA - chest
2024-09-09 2D transthoracic echocardiography
2024-07-04 CXR
2024-07-01 CXR
2024-06-25 CXR
2024-06-12 Sonographty - veins
2024-01-23 Sonography - nephrology
2023-10-13 Sonography - abdomen
2023-08-30 2D transthoracic echocardiography
2023-06-20 Esophagogastroduodenoscopy, EGD
2023-03-31 Sonography - nephrology
2022-09-01 Sonography - abdomen
[MedRec]
2025-12-17 SOAP Hemato-Oncology Xia HeXiong
2025-12-17 SOAP Cardiac Surgery Shen DaZhong
2025-11-19 SOAP Metabolism and Endocrinology Hu YaHui
2025-10-01 ~ 2025-10-29 POMR
2025-06-09 ~ 2025-06-11 POMR
2025-01-08 ~ 2025-01-24 POMR
2024-10-01 ~ 2024-11-07 POMR
2024-07-05 ~ 2024-07-13 POMR
2024-06-27 ~ 2024-07-01 POMR
2023-06-20 ~ 2023-06-23 POMR
2021-08-23 ~ 2021-09-01 POMR
2018-06-07 ~ 2018-06-09 POMR
2014-11-29 ~ 2014-12-05 POMR
2012-08-22 ~ 2012-08-27 POMR
2012-07-11 ~ 2012-07-20 POMR
[consultation]
2025-12-18 Nephrology
2025-10-14 Vascular Surgery
2025-10-02 Oral and Maxillofacial Surgery
[surgical operation]
2025-11-25
2024-10-23
2024-10-08
2024-10-04 22:30
2024-10-04 14:25
2017-06-16
[medication]
Femara (letrozole 2.5mg)
Xgeva (denosumab 120mg)
Nolvadex (tamoxifen 10mg)
warfarin
Key Insights/Summary
Problem 1. Acute on chronic kidney injury on CKD stage 4 with electrolyte/volume vulnerability
Problem 2. Electrolyte and acid-base derangements: hyperkalemia episodes, hyponatremia, severe hypocalcemia, hypophosphatemia, borderline hypomagnesemia
Problem 3. Markedly supratherapeutic anticoagulation on warfarin with high INR/PT/aPTT and high bleeding risk
Problem 4. Severe anemia with transfusion requirement; borderline thrombocytopenia
Problem 5. Suspected severe bacterial infection/sepsis risk with prior fever; currently on antibiotics
Problem 6. Cardiovascular disease: atrial fibrillation, mechanical valve history, chronic diastolic heart failure; QT prolongation risk
Problem 7. Type 2 diabetes with nephropathy: inpatient glycemic management under AKI
Problem 8. Breast cancer history with bone pain; ongoing endocrine/supportive therapies and symptom burden
Problem 9. Medication safety and regimen complexity in CKD4/AKI, QT prolongation, and constipation risk
[exam finding]
2025-12-09 Cardiac Catheterization
2025-12-09 CXR
2025-12-08 03:58 ECG
2025-12-08 01:24 ECG
2025-08-22 2D transthoracic echocardiography
2025-03-31 Cardiac Catheterization
2025-01-16 Myocardial Perfusion SPECT with persantin
2024-10-24 2D transthoracic echocardiography
2024-03-14 2D transthoracic echocardiography
2023-09-25 Cardiac Catheterization
2023-08-22 Myocardial Perfusion SPECT with persantin
2023-06-06 2D transthoracic echocardiography
[MedRec]
2025-12-08 ~ 2025-12-10 POMR Cardiology Zhou XingHui
2025-10-01, 2025-07-02 SOAP Cardiology Zhou XingHui
2025-03-30 ~ 2025-04-01 POMR Cardiology Zhou XingHui
2023-09-24 ~ 2023-09-26 POMR Cardiology Zhou XingHui
[Subjective]
Pharmacist outreach and shared decision-making
Medication adherence and fluid management
[Objective]
Recent coronary and heart failure status
Renal function and dialysis dependence
Metabolic risk factors
Discharge cardiovascular medications (most recent available list)
[Assessment]
High ischemic risk requiring urgent shared decision-making on revascularization
Medication adherence is critical, but antiplatelet strategy must be synchronized with CABG timing
Poor glycemic control is a modifiable perioperative and cardiovascular risk factor
ESRD on hemodialysis amplifies cardiovascular risk and complicates fluid and medication management
[Plan / Recommendation]
Shared decision-making and care coordination
Medication adherence and optimization (pharmacist-led)
Glycemic control actions (practical, measurable)
Fluid and dialysis-related counseling
Documentation improvements for the pharmacist note (for completeness and downstream care)
Key insights/summary
Problem 1. Acute coronary syndrome (NSTEMI) with very high risk coronary anatomy (distal LMCA + triple-vessel CAD, high SYNTAX)
Problem 2. Acute decompensated heart failure due to ischemic cardiomyopathy (volume overload on ESRD), with chronically reduced LVEF
Problem 3. End stage renal disease on chronic hemodialysis with high cardiovascular and procedural risk
Problem 4. Diabetes mellitus with poor glycemic control and hyperglycemic crisis risk
Problem 5. Hypertension and hypertensive heart disease in the setting of ischemic cardiomyopathy and ESRD
Problem 6. Medication management and bleeding/ischemia balance (DAPT, GI protection, QT risk)
Problem 7. Possible pulmonary process on chest imaging (pulmonary edema resolved vs infection/atelectasis)
Problem 8. Anemia of chronic disease/ESRD and hematologic monitoring (currently mild)
Problem 9. Other clinically relevant findings (fracture on imaging, vascular calcification)
[CABG in this patient: pros and cons with rationales]
Clinical context anchoring (why CABG is on the table) - Coronary anatomy is very high risk and complex - Distal LMCA 63% stenosis with bifurcation Medina 1.1.1 (Cardiac catheterization 2025-12-09) - Triple-vessel CAD with severe LAD/LCx disease and distal RCA total occlusion (Cardiac catheterization 2025-12-09) - High SYNTAX score 39, with cath recommendation to consult CVS and treat CABG as default strategy (Cardiac catheterization 2025-12-09) - High ischemic risk presentation - NSTEMI with hs-Troponin I rise 59.3 -> 620.5 pg/mL (lab 2025-12-08) - Heart failure decompensation physiology with NT-proBNP >35000 pg/mL and pulmonary edema improved after hemodialysis/therapy (lab 2025-12-08; MedRec 2025-12-08 to 2025-12-10) - Major comorbidities shaping benefit-risk - Diabetes with HbA1c 8.3% (lab 2025-12-10) - ESRD on regular hemodialysis with creatinine 9.46 and eGFR 6.14 (lab 2025-12-08; MedRec 2025-12-08 to 2025-12-10) - Ischemic cardiomyopathy with chronically reduced LVEF on echo 32-35% (echo 2024-10-24; echo 2025-08-22), though ventriculography EF 48.3% during admission (Cardiac catheterization 2025-12-09)
Pros of CABG (why CABG is attractive in this specific patient)
Cons of CABG (what makes CABG risky or challenging in this patient)
How to frame the decision (practical synthesis for this patient)
Actionable next steps to reduce uncertainty and make CABG safer
[exam finding]
2025-10-20 ECG
2025-10-19, 2025-08-18, 2025-08-08, 2025-07-25, 2025-06-30, 2025-05-30, 2025-05-21, 2025-05-05, 2025-04-24 CXR
2025-10-18 MRI - brain
2025-09-26 Knee Bilat
2025-09-19 CT - chest
2025-06-18 PET
2025-06-17 Sonography - chest
2025-05-23 CT - abdomen
2025-03-22 CT - chest
2025-03-12 MRI - brain
2025-02-17, 2025-01-22, 2024-12-27 CXR
2025-01-16 Tc-99m MDP bone scan with SPECT
2024-12-18 Sonography - chest
2024-12-17 CT - chest
2024-12-09 Patho - soft tissue biopsy / simple excision (non lipoma)
2024-12-05 CXR
2024-11-23 MRI - brain
2024-11-22 CXR
2024-11-15 CT - abdomen
2024-11-11 L-spine Ap + Lat (including sacrum)
2024-10-28 CXR
2024-10-23 Sonography - chest
2024-10-15 CT - chest
2024-08-24 MRI - brain
2024-08-16 CT - chest
2024-07-01 CXR
2024-07-01 KUB
2024-06-20 Neurosonography
2024-06-14 EEG
2024-06-13 MRI - brain
2024-06-13 Sonography - chest
2024-06-12 CT - chest
2024-06-03 ALK IHC
2024-05-27 PD-L1 (28.8)
2024-05-22 ROS1 IHC
2024-05-22 PD-L1 (22C3)
2024-05-22 EGFR gene mutation test
2024-05-22 CXR
2024-05-15 Patho - lung total/lobe/segmental
2024-05-09 2D transthoracic echocardiography
2024-05-07 Flow Volume Chart
2024-05-02 PET
2024-05-02 CXR
2024-04-30 Tc-99m MDP bone scan with SPECT
2024-04-30 Sonography - breast
2024-04-30 Patho - colon biopsy
2024-04-28 CXR
2024-04-23 CT - abdomen
2024-04-23 CXR
2024-04-19 MRA - brain
[MedRec]
2025-08-04 SOAP Radiation Oncology Chang YouKang
2024-06-05 MultiTeam - Psycho-oncology
2024-06-04 Shared Decision-Making, SDM
2024-04-26 ~ 2024-07-04 POMR Integrative Medicine Yang MuJun
[consultations]
2024-10-14 Oral and maxillofacial surgery
2024-08-16 Thoracic surgery
2024-06-18 Dermatology
2024-06-18 Neurosurgery
2024-05-10 Ophthalmology
2024-05-07 Thoracic surgery
2024-04-26 Radiation Oncology
2024-04-19 Neurosurgery
[surgical operation]
[radiotherapy]
2025-07-23 ~ 2025-08-04 - 3150cGy/9 fractions (6 MV photon) to Rt lower pleural tumor
2025-06-29 ~ 2025-07-17 - 4800cGy/12 fractions (15 MV photon) to Rt adrenal tumor
[immunochemotherapy]
Key insights/summary
Problem 1. Severe anemia (high immediate risk)
Problem 2. Thrombocytopenia with bleeding risk (and procedure/safety implications)
Problem 3. Leukopenia/neutropenia risk and infection susceptibility
Problem 4. Chronic kidney disease and platinum-associated nephrotoxicity constraint
Problem 5. Metastatic lung adenocarcinoma on later-line chemotherapy (disease control vs tolerance balance)
Problem 6. Brain metastasis, VP shunt status, seizure/cognitive vulnerability, and fall risk
Problem 7. Chronic pleural space disease and infection risk (post-treatment empyema vs chronic inflammation)
Problem 8. Hepatitis B core antibody positivity with antiviral prophylaxis management under CKD
Problem 9. Medication safety and regimen rationalization (sedation, anticholinergic burden, duplications, and indication clarity)
Problem 10. Constipation risk (baseline + medication-driven)
Problem 11. Nutritional status and hypoalbuminemia (frailty/treatment tolerance)
Problem 12. Psychosocial distress, cognitive impairment, and decision-support needs
Key insight / summary
Problem 1. Metastatic KRAS G12C lung adenocarcinoma — current disease control and strategy
Problem 2. Renal impairment — likely cisplatin nephrotoxicity, currently stage 3a by eGFR
Problem 3. Chemotherapy-induced cytopenias — anemia, leukopenia/neutropenia, thrombocytopenia
Problem 4. Hypomagnesemia and electrolyte risk (cisplatin-related)
Problem 5. Right pleural disease with chronic effusion and prior empyema
Problem 6. Brain metastasis with VP shunt; seizure disorder
Problem 7. HBV core antibody positive on immunosuppression
Problem 8. Anti-infective stewardship and QT risk
Problem 9. Historical small pulmonary embolism and thrombosis risk
Problem 10. Symptom control, sleep, and drug-interaction hygiene
Closing logistics
Since the last review, the patient with advanced right lower lobe lung adenocarcinoma (pT1cN1M1b IVA, KRAS G12C mutation, brain and multiple systemic metastases) has undergone sequential multi-line treatments including surgery, radiotherapy, immunotherapy, and various chemotherapy regimens. PET on 2025-06-18 showed progressive disease with pleural, mediastinal, and adrenal metastases, prompting a shift to gemcitabine plus cisplatin from 2025-07-18. Treatment has been complicated by fluctuating hematologic parameters - most notably severe chemotherapy-induced myelosuppression on 2025-08-08 with WBC 1.64 ×10³/μL and PLT 157 ×10³/μL - followed by rebound leukocytosis (12.62 ×10³/μL) with neutrophilia (90.5%) and anemia (HGB 8.8 g/dL) by 2025-08-11. Electrolyte stability is generally preserved except for recurrent hypomagnesemia. The patient maintains ECOG PS 2, afebrile, with relatively stable hemodynamics and oxygenation.
Problem 1. Advanced metastatic lung adenocarcinoma with disease progression
Problem 2. Chemotherapy-induced myelosuppression with anemia and leukocyte fluctuations
Problem 3. Recurrent hypomagnesemia
Problem 4. Electrolyte and renal function monitoring during cisplatin therapy (not posted)
Problem 5. Symptom control and functional status (not posted)
This 59-year-old woman with stage IVA right lower lobe lung adenocarcinoma (pT1c, pN1, cM1c), complicated by pontine metastasis and prior obstructive hydrocephalus (VP shunt on 2024-06-25), remains on systemic therapy. She has received multimodal chemotherapy including pemetrexed/cisplatin, docetaxel/pembrolizumab, paclitaxel/carboplatin/pembrolizumab, and currently pembrolizumab with Mvasi (bevacizumab biosimilar).
Recent labs show anemia (HGB 9.4), thrombocytopenia (PLT 128), and elevated tumor markers (CEA 83.98 ng/mL, CA199 71.64 U/mL as of 2025-05-30).
CT and chest sono (2025-05-23 and 2025-06-17) confirm persistent encapsulated right pleural effusion, suspicious for pleural metastasis. Brain MRI (2025-03-12) shows stable pontine metastasis.
She is admitted for C2 immunotherapy and PET scan evaluation.
Problem 1. Right Lower Lobe Lung Adenocarcinoma, Stage IVA with Pleural and Brain Metastases
Problem 2. Anemia and Thrombocytopenia under Immunochemotherapy (below not posted)
Problem 3. Right-Sided Encapsulated Pleural Effusion and Empyema Sequelae
Problem 4. Chronic Hepatitis B (Anti-HBc Positive, HBsAg Negative)
Problem 5. Neurological Sequelae from Pontine Metastasis and Post-VP Shunt
Problem 6. Pain and Sleep Disturbance
Key Summary Since 2024-12-17
Problem 1: Worsening Anemia (Normocytic Normochromic)
Problem 2: Persistent Right Pleural Effusion & Lung Disease
Problem 3: Bone Scan Progression – L-Spine Lesions
Active Medication Review (below not posted)
Summary of Key Changes Since 2024-12-17
| Issue | 2024-12-17 | 2025-03-10 | Trend |
|---|---|---|---|
| Anemia (HGB g/dL) | ~8.5-9.0 | 7.9 | ↓ Worsening |
| Pleural Effusion | Present | Persistent | No Resolution |
| Bone Scan (L-Spine) | Mild Uptake | Increased Uptake | Possibly Worse |
| Chemotherapy | Ongoing | Adjustments in paclitaxel dosing (80%-90%) | Dose Adjusted |
| Renal Function (eGFR mL/min) | 105-110 | 106.7 | Stable |
| Liver Function (AST/ALT U/L) | Normal | Stable | Stable |
Next Steps
Conclusion: The patient remains stable but exhibits worsening anemia, persistent lung abnormalities, and progressive bone scan changes, requiring targeted interventions and monitoring.
[Patient Summary]
The 59-year-old female patient presents with stage IVA right lower lobe lung adenocarcinoma (pT1c, pN1, cM1c), confirmed with metastatic lesions involving the left pons and abdominal wall. She has a history of video-assisted thoracoscopic surgery (VATS) for right middle lobe wedge resection, right lower lobectomy, and radical lymph node dissection (2024-05-14).
[Problem-Oriented Comments]
[Medication Review]
[exam finding]
2025-11-11 ECG
2025-11-11 CXR
2025-10-30 ALK IHC
2025-10-27 CXR
2025-10-23 MRI - brain
2025-10-21 ROS1 IHC
2025-10-21 PD-L1 (22C3)
2025-10-21 EGFR
2025-10-21 Sonography - thyroid gland
2025-10-20 CXR
2025-10-17 Tc-99m MDP bone scan with SPECT
2025-10-16 Sonography - breast
2025-10-16 2D transthoracic echocardiography
2025-10-15 Pathology - lung wedge biopsy
2025-10-14 CXR
2025-10-09 CT - chest
Chest CT with and without IV contrast enhancement
Chest findings
Visible abdomen findings
Impression
Imaging report form for lung carcinoma
[MedRec]
2025-12-11 ~ 2025-12-13 POMR Hemato-Oncology Gao WeiYao
2025-12-11 SOAP Radiation Oncology Huang JingMin
2025-11-11 ~ 2025-11-14 POMR Hemato-Oncology Gao WeiYao
2025-11-04 SOAP Hemato-Oncology Gao WeiYao
2025-10-21 MultiTeam - Cancer case manager
2025-10-14 ~ 2025-10-30 POMR Hemato-Oncology Gao WeiYao
2025-10-14 SOAP Hemato-Oncology Gao WeiYao
2025-10-09 SOAP Hemato-Oncology Gao WeiYao
[surgical operation]
2025-10-20
[chemotherapy]
[Subjective]
Follow-up for post-treatment nausea/vomiting and appetite
[Objective]
Cancer status and recent treatments
Recent admission for nausea/poor appetite and discharge regimen
Pertinent labs around the nausea admission
[Assessment]
Post-chemotherapy and post-brain-RT nausea/vomiting, currently improved with discharge regimen
Ongoing risks needing monitoring despite symptomatic improvement
[Plan / Recommendation]
Antiemetic regimen optimization and patient education
Monitoring and escalation thresholds
Electrolytes and supportive care
Preparation for upcoming therapy and safety reminders
Follow-up plan
[Subjective]
Cancer treatment-related symptoms (2025-11-19)
Understanding of treatment and self-monitoring
Diet, infection prevention, and hepatitis B
Physical activity and possible sarcopenia
[Objective]
Cancer diagnosis, staging, and treatment course
Hepatitis B and antiviral prophylaxis
Recent laboratory data
Cardiac status
Immunotherapy (planned)
[Assessment]
Cancer-treatment-related fatigue, anorexia, and possible early sarcopenia
Chemotherapy-induced nausea and GI symptoms (currently controlled, but still bothersome)
Cardiovascular risk: palpitations and history of large pericardial effusion
Hematologic nadir and risk of anemia-related fatigue
Infection risk and food safety
Chronic hepatitis B and Vemlidy (tenofovir alafenamide) adherence
Electrolyte changes and hydration status (post-cisplatin)
Education on future pembrolizumab (not yet started)
Exercise counseling and sarcopenia prevention (area for improvement)
[Plan / Recommendation]
Fatigue, anorexia, and suspected early sarcopenia
Chemotherapy-induced nausea and GI symptom management
Cardiovascular monitoring and palpitations
Hematologic nadir and anemia-related fatigue
Infection risk, food safety, and activity
Hepatitis B management and Vemlidy (tenofovir alafenamide)
Electrolytes and hydration
Education for pembrolizumab (anticipatory)
Exercise and sarcopenia: improvement of pharmacist role
Documentation and follow-up
key insights / summary (as of 2025-11-12)
Problem 1. Metastatic non-squamous NSCLC, driver-negative to date, on platinum/pemetrexed
Problem 2. Large pericardial effusion without tamponade
Problem 3. Brain metastases (two 5 mm lesions, left frontal)
Problem 4. Possible bone metastasis (left 2nd rib) and skeletal health
Problem 5. HBV reactivation risk during chemotherapy
Problem 6. Chemotherapy-induced nausea risk and current supportive care
Problem 7. Cardiovascular risk signal: ECG ‘anterior infarct, age undetermined’ and exertional chest tightness history
Problem 8. Hematology and organ function surveillance
Problem 9. Right outer breast enhanced lesion on CT requiring correlation
Problem 10. Active medication reconciliation and safety
Disposition and follow-up anchors
Medication/treatment-related problems to be concerned (as of 2025-11-12)
[exam finding]
2025-12-10 CXR
2025-12-05 CXR
S/P port-A implantation. Enlargement of cardiac silhouette. S/P Mastectomy, left. Massive right Pleura effusion Increase soft tissue density projecting at right lower chest wall is suspected. Please correlate with CT.
2025-11-27 CXR
2025-11-25 CXR
2025-11-25 ECG
2025-11-24 Sonography - chest
2025-11-21 Pathology - breast biopsy (no need margin)
2025-11-17 CT - chest
2025-11-14 CXR
2025-11-14 ECG
[MedRec]
2025-12-05 SOAP Hemato-Oncology Gao WeiYao
2025-12-02 MultiTeam - Social Services
2025-11-30 MultiTeam - Wound care
2025-11-21 MultiTeam - Wound care
2025-11-14 MultiTeam - Wound care
2025-11-14 ~ 2025-12-02 POMR Integrative Medicine Zheng YuMing
[consultation]
2025-12-12 Radiation Oncology
2025-11-18 Hemato-Oncology
2025-11-17 General and Gastroenterological Surgery
[medication]
Navelbine (vinorelbine 20mg) 1# QW
Key insight/summary
Problem 1. Acute and chronic respiratory compromise from massive right pleural effusion with right lung collapse
Problem 2. Locally advanced triple-negative right breast cancer with aggressive biology and rapid progression after treatment gap
Problem 3. Malignant fungating breast wound with bleeding and suspected infection/colonization
Problem 4. Microcytic anemia with reactive thrombocytosis, likely chronic blood loss and inflammation, in the context of active cancer
Problem 5. Cancer-associated thrombosis risk and possible venous thromboembolism
Problem 6. Hypoalbuminemia, malnutrition/cachexia, and related electrolyte abnormalities
Problem 7. Pain control, dyspnea symptom management, and medication safety (opioids, sedatives, acetaminophen)
Problem 8. Marked eosinophilia and leukocytosis in the context of malignancy, infection, and medications
Problem 9. Cardiovascular considerations: troponin elevation, low voltage QRS, and enlarged cardiac silhouette
Problem 10. Hepatitis B serology pattern (anti-HBc positive, HBsAg negative) and immunosuppression-related reactivation risk
[lab data]
2025-10-07 Bone Marrow Chromosome Analysis
[exam finding]
2025-12-02 Thallium-201 myocardial perfusion imaging
2025-10-28 2D transthoracic echocardiography
2025-09-09 Sonography - abdomen
2025-09-08 Pathology - bone marrow biopsy
[MedRec]
2025-11-04 SOAP Hemato-Oncology Gao WeiYao
2025-09-04 ~ 2025-09-09 POMR Hemato-Oncology Lin YiTing
[chemotherapy]
[medication]
Venclexta (venetoclax 100mg) 1# QDCC
Jadenu (deferasirox 360mg) 1# BID
Vemlidy (tenofovir alafenamide 25mg) 1# QD
[Medication- and treatment-related problems to be concerned about]
Problem 1. Clinically significant drug-drug interaction: Noxafil (posaconazole) with Venclexta (venetoclax)
Problem 2. Treatment-related prolonged cytopenias and infection/bleeding risk under HMA/Venetoclax strategy
Problem 3. TLS prevention and monitoring plan around Venclexta (venetoclax) initiation or re-initiation
Problem 4. Jadenu (deferasirox) safety in the setting of fluctuating hepatic indices and ongoing transfusion dependence
Problem 5. Antifungal prophylaxis benefit versus toxicity balance (Noxafil (posaconazole))
Problem 6. Antihypertensive regimen and PRN agents: hypotension or overcorrection risk versus uncontrolled blood pressure
Problem 7. HBV management continuity: Vemlidy (tenofovir alafenamide) stopped earlier despite planned immunosuppressive therapy trajectory
Problem 8. Sedating or allergic-symptom PRN therapy: Benadryl (diphenhydramine) and fall or aspiration risk
Problem 9. Regimen strategy alignment and sequencing: Vidaza (azacitidine) plus Venclexta (venetoclax) in higher-risk MDS and safe operationalization
[POMR - updated version]
Key insights/summary
Problem 1. High-risk myelodysplastic syndrome with increased blasts-2 (MDS-IB2), complex karyotype, high risk of AML transformation
Problem 2. Severe anemia with transfusion dependence, mixed etiology suspected (marrow failure plus possible hemolysis plus possible gastrointestinal blood loss)
Problem 3. Severe thrombocytopenia with active bleeding risk
Problem 4. Neutropenia and infection risk with inflammatory signal
Problem 5. Structural heart disease with possible ischemia/hibernating myocardium and LV dilatation
Problem 6. Poorly controlled hypertension with aortic root dilatation and atherosclerotic burden
Problem 7. Iron overload due to chronic transfusion exposure, on chelation therapy
Problem 8. Hyperbilirubinemia with mixed direct fraction, fatty liver, and possible hemolysis contribution
Problem 9. Supportive care regimen, drug interactions, and prophylaxis completeness during venetoclax-based therapy
[POMR - earlier version]
Key Insights/Summary
Problem 1. High-risk MDS-IB2 with complex karyotype and high risk of AML transformation
Problem 2. Severe cytopenias from marrow failure with transfusion dependence and high bleeding risk
Problem 3. Suspected GI bleeding and mucosal bleeding in the setting of severe thrombocytopenia
Problem 4. Possible hemolysis and/or immune-mediated anemia superimposed on MDS (Direct Coombs positive, low haptoglobin, reticulocytosis, hyperbilirubinemia)
Problem 5. Cardiovascular disease risk: LV/LA dilation, diastolic dysfunction, possible myocardial ischemia/hibernation, hypertension, and profound anemia as a trigger
Problem 6. Infection and inflammation risk in neutropenia on intensive therapy (azacitidine/venetoclax) with elevated CRP
Problem 7. Hepatobiliary abnormalities and fatty liver with hyperbilirubinemia; need to separate cholestasis from hemolysis
Problem 8. Secondary iron overload from chronic transfusions with ongoing chelation therapy
Problem 9. Hepatitis B status and reactivation prevention under immunosuppressive therapy
Problem 10. Electrolyte and metabolic issues: mild hyponatremia and borderline hypocalcemia; TLS vigilance with venetoclax
Medication reconciliation (from provided records)
[Differential Diagnosis Using Laboratory Tests and Physical Examination Alone]
Life-threatening rule-out: Acute coronary syndrome or demand ischemia with critical anemia
Next steps to narrow and confirm
[lab data]
2025-06-30 FLT3-D835 (BM) Undetectable
2025-06-30 NPM1 mutation (qual) (BM) Presence of mutation
2025-06-26 BCR/abl (BM) Ph (qual) Undetectable
2025-06-26 FLT3/ITD mutation (BM) Undetectable
2025-06-26 JAK2 mutation (quan) 0.00 %
2025-06-21 HSV 1 IgG Positive
2025-06-21 HSV 1 IgG Value 57.60
2025-06-21 HSV 2 IgG Positive
2025-06-21 HSV 2 IgG Value 1.29
2025-06-21 HSV 1+2 IgM Negative
2025-06-21 HSV 1+2 IgM Value <0.50 Index
2025-06-19 B2-Microglobulin 2470 ng/mL
2025-06-19 CMV_IgG Reactive
2025-06-19 CMV_IgG Value 1044.9 AU/mL
2025-06-19 CMV IgM Nonreactive
2025-06-19 CMV IgM Value 0.07 Index
2025-06-19 Anti HTLV I/II Nonreactive
2025-06-19 Anti HTLV I/II Value 0.10 S/CO
2025-06-19 HBsAg Nonreactive
2025-06-19 HBsAg (Value) 0.31 S/CO
2025-06-19 Anti-HBs 14.87 mIU/mL
2025-06-19 Anti-HBc Reactive
2025-06-19 Anti-HBc-Value 6.02 S/CO
2025-06-19 Anti-HCV Nonreactive
2025-06-19 Anti-HCV Value 0.14 S/CO
2025-06-19 HIV Ab-EIA Nonreactive
2025-06-19 Anti-HIV Value 0.06 S/CO
[exam finding]
2025-12-08 CXR
2025-12-08 ECG
2025-10-07 2D transthoracic echocardiography
2025-08-18 CXR
2025-06-27 Sonography - abdomen
2025-06-19 Pathology - bone marrow biopsy
2025-06-19 CXR
2025-06-17 CXR
2025-06-17 ECG
2025-05-26 CXR
2025-05-24 ECG
2025-05-24 2D transthoracic echocardiography
2025-05-23 CXR
2025-05-23 Cardiac Catheterization
2025-05-23 Transesophageal Echocardiography, TEE
2025-05-22 ECG
2025-04-28 Cardiac Catheterization
2025-04-25 CT - for TAVI
2025-04-18 CT - abdomen
2025-04-17 2D transthoracic echocardiography
2025-04-16 Pathology - bone marrow biopsy
2025-04-16 Sonography - abdomen
2025-04-14 ECG
2025-04-14, 2025-02-14 CXR
2024-03-04 2D transthoracic echocardiography
2023-03-14 Neurosonography
2022-07-21 Hearing Test
[MedRec]
2025-12-08 ~ 2025-12-15 POMR Hemato-Oncology Lin YiTing
2025-12-08 SOAP Hemato-Oncology Lin YiTing
2025-06-18 ~ 2025-06-30 POMR Hemato-Oncology Lin YiTing
2025-05-22 ~ 2025-05-27 POMR Cardiac Surgery Shen DaZhong
2025-04-14 ~ 2025-04-30 POMR Cardiac Surgery Shen DaZhong
[chemotherapy]
Key insights / summary
Problem 1. Acute myeloid leukemia with maturation, NPM1(+), FLT3(–), in a 90-year-old with prior pancytopenia
Problem 2. Severe cytopenias with DIC tendency and transfusion dependence
Problem 3. Hyperleukocytosis risk, tumor lysis, and metabolic profile
Problem 4. Complex cardiovascular disease: severe AS s/p TAVR, atrial fibrillation, triple-vessel CAD, valvular disease, aortic aneurysms
Problem 5. Infection risk: neutropenia, UTI, pneumonia, and current antimicrobial strategy
Problem 6. Renal function, electrolytes, and metabolic status
Problem 7. Functional status, musculoskeletal issues, neurologic history, and geriatric considerations
Problem 8. Risk of HBV reactivation under current AML therapy
Objective
Assessment
Recommendation
Problem 9. Iron overload
[exam finding]
2025-11-27 CT - abdomen
2025-11-03 KUB
2025-11-03 ECG
2025-10-17, 2025-09-29 CXR
2025-10-08 ECG
2025-09-12 2D transthoracic echocardiography
2025-09-08 ECG
2025-08-30 CXR
2025-08-30 Colonoscopy
2025-08-28 Visceral Angiography over 2 vessels
2025-08-27 ECG
2025-08-27 Sigmoidoscopy
2025-08-20 ECG
2025-07-24 CXR
2025-07-21 ACTOnco+
2025-07-17 Pathology - pancreas biopsy
2025-07-16 MRI - pancreas
2025-07-16 Pathology - colon biopsy
2025-07-16 ECG
2025-07-16 Endoscopic Ultrasonography, EUS
2025-07-15 Colonoscopy
2025-07-15 Sonography - abdomen
2025-07-14 Pathology - stomach biopsy
2025-07-14 ECG
2025-07-14 Esophagogastroduodenoscopy, EGD
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
Key insights/summary
Problem 1. Life-threatening electrolyte derangements (hypokalemia with hypomagnesemia and hypocalcemia)
Problem 2. Severe anemia with recent rapid decline, transfusion planning, and bleeding risk
Problem 3. Metastatic pancreatic ductal adenocarcinoma on dose-reduced FOLFIRINOX and prior radiotherapy
Problem 4. Chemotherapy toxicities and supportive care optimization (nausea/vomiting, dehydration risk)
Problem 5. Diabetes mellitus with variable glycemia on insulin-based regimen during chemotherapy
Problem 6. Borderline hypotension and cardiovascular conduction disease (RBBB, PACs) in the setting of electrolyte derangements and antihypertensives
Problem 7. Medication-related safety concerns and interaction risks (electrolytes, antiemetics, antiarrhythmics)
Problem 8. Infection surveillance and urinary findings (culture interpretation, chemo-associated risk)
Problem 9. Malnutrition/hypoalbuminemia and functional reserve during systemic therapy
Problem 10. Post-operative LUQ collection, possible splenic infarct, and ileus risk
Problem 11. Hepatitis B core antibody positivity on antiviral prophylaxis
Key insight/summary
Problem 1. Post-chemotherapy myelosuppression neutropenia with severe anemia and thrombocytopenia
Problem 2. Electrolyte derangements with metabolic alkalosis (from GI losses) and risk of arrhythmia
Problem 3. Infection risk in neutropenia; current data suggest no septic shock, possible urinary contamination; empiric coverage on board
Problem 4. Gastrointestinal toxicity post-FOLFIRINOX (nausea, vomiting, diarrhea) with dehydration risks and GI bleed history
Problem 5. Hyperglycemia in type 2 diabetes on basal–bolus insulin, steroid-exacerbated
Problem 6. Metastatic pancreatic ductal adenocarcinoma — status and trajectory under chemo-RT
Problem 7. Chronic hepatitis B on prophylaxis during immunosuppression
Problem 8. Conduction disease/arrhythmia risk with electrolyte shifts
Ancillary/ongoing items (today)
Active inpatient medications noted (mapping)
Increasing atropine premedication to 0.5 mg before irinotecan administration is clinically reasonable and supported by practice guidelines.
The patient is a 68-year-old male with stage IV pancreatic tail adenocarcinoma invading hepatic flexure colon, stomach, and spleen, with liver metastases (T3N1M1), on chemotherapy with FOLFIRINOX (Q2W), admitted for C1D15 cycle (2025-08-10). Comorbidities include type 2 diabetes mellitus, hypertension, and chronic hepatitis B (on Vemlidy since 2025-07-21). He presented with prior anemia due to gastrointestinal bleeding and is expected to be stable post-transfusion. Notable issues during this admission include hypomagnesemia (Mg 1.4 mg/dL), hyponatremia (Na 129 mmol/L on 2025-08-10), and fluctuating hyperglycemia (297–454 mg/dL). Vitals remain stable with ECOG PS 1, no acute respiratory or cardiovascular compromise. Port-A site is clean without infection.
Problem 1. Stage IV pancreatic tail adenocarcinoma with multiorgan invasion and liver metastases
Problem 2. Anemia (acute posthemorrhagic, likely GI bleeding-related)
Problem 3. Hypomagnesemia
Problem 4. Hyponatremia (not posted)
Problem 5. Hyperglycemia (T2DM on insulin and oral agents)
[exam finding]
2025-12-12 ECG
2025-04-22 CXR
2025-04-21 Portable 24hr ECG
2025-04-21 2D transthoracic echocardiography
2025-04-18 23:17 ECG
2025-04-18 CT - abdomen
2025-04-18 Sonography - nephrology
2025-04-17 Sonography - chest
2025-04-16 LUB
2025-04-16 CXR
2025-04-16 17:14 ECG
2025-02-05 Neurosonography
2024-05-06, 2024-04-26 CXR
2024-04-24 Sonography - chest
2024-04-06 CT - brain
2024-04-06 ECG
2024-04-03 2D transthoracic echocardiography
2024-02-02 Nasopharyngoscopy
2024-02-02 Sonography - head and neck, soft tissue
2024-01-31 CXR
2024-01-31 2D transthoracic echocardiography
2024-01-29 KUB
2024-01-27 ECG
2024-01-27 CXR
2024-01-27 CT - brain
2023-09-12 MRA - brain
2023-09-11 2D transthoracic echocardiography
2023-09-09 CTA - brain (head and neck)
2023-09-09 CT - brain
2023-09-09 ECG
2023-06-13 Pathology - urinary bladder TUR
2023-06-12 ECG
2023-05-25 CT - abdomen
2023-03-01 Shoulder Rt
2023-03-01 Bone densitometry - Spine + Hip
2022-08-30 Pathology - urinary bladder TUR
2022-08-29 ECG
2022-08-17 CT - abdomen
2020-11-28 CT - chest
2020-10-21 Neurosonography
2020-10-21 2D transthoracic echocardiography
[MedRec]
2025-10-01, 2025-07-09, 2025-05-14, 2024-05-16, 2025-01-22 SOAP Neurology Chen PeiYa
2025-10-01, 2025-07-09, 2025-04-16, 2025-01-22 SOAP Chest Medicine Li Zhong
2025-04-17 ~ 2025-04-23 POMR Integrative Medicine Yang MuJun
2024-04-03 ~ 2024-05-07 POMR Integrative Medicine Li Zhong
2024-01-27 ~ 2024-02-02 POMR Nephrology Hong SiQun
2023-09-09 ~ 2023-11-08 POMR Neurology Chen PeiYa
2023-06-12 ~ 2023-06-15 POMR Urology Xu JunKai
2022-08-29 ~ 2022-09-01 POMR Urology Xu JunKai
[chemotherapy]
2023-06-15 - mitomycin-C 30mg/m2 30mg BI 1hr
2022-10-05 - mitomycin-C 30mg/m2 30mg BI 1hr
2022-09-28 - doxoribucin 30mg/m2 30mg BI 1hr
2022-09-21 - cisplatin 30mg/m2 30mg BI 1hr
2022-09-14 - cisplatin 30mg/m2 30mg BI 1hr
2022-09-07 - mitomycin-C 30mg/m2 30mg BI 1hr
2022-08-31 - mitomycin-C 30mg/m2 30mg BI 1hr
Key insights / summary
Problem 1. Acute post-hemorrhagic and iron deficiency anemia on chronic recurrent anemia
Problem 2. Chronic respiratory failure with ventilator dependence and pleural effusions (currently stable)
Problem 3. Chronic atrial fibrillation, sinus node dysfunction / conduction disease, and anticoagulation under structural heart disease
Problem 4. Chronic kidney disease with prior AKI episodes, now improving; associated electrolyte disturbances
[lab data]
2025-12-05 Free Light Chain κ/λ; 免疫球蛋白κ/λ,(blood) ratio
2025-12-05 FKLC 18.78 mg/L
2025-12-05 FLLC 8.37 mg/L
2025-12-05 FK/FL ratio 2.24 ratio
2025-12-02 IgG (blood) 504 mg/dL
2025-11-17 Free Light Chain κ/λ; 免疫球蛋白κ/λ,(blood) ratio
2025-11-17 FKLC 17.70 mg/L
2025-11-17 FLLC 6.90 mg/L
2025-11-17 FK/FL ratio 2.57 ratio
2025-11-11 IgG (blood) 491 mg/dL
2025-11-07 Free Light Chain κ/λ ratio
2025-11-07 FKLC 22.09 mg/L
2025-11-07 FLLC 7.05 mg/L
2025-11-07 FK/FL ratio 3.13 ratio
2025-11-06 EB VCA IgG Positive Ratio
2025-11-06 EB VCA IgG Value 1.4 Ratio
2025-11-06 B2-Microglobulin 2465 ng/mL
2025-11-06 CMV viral load assay 41.5 IU/mL
2025-11-06 VZV IgM (blood) Index
2025-11-06 VZV IgM Negative Index
2025-11-06 VZV IgM Value 0.15 Index
2025-11-05 EB-VCA IgM U/mL
2025-11-05 EB VCA IgM NEGATIVE U/mL
2025-11-05 EB VCA IgM Value <10.0 U/mL
2025-11-05 VZV IgG (blood) mIU/mL
2025-11-05 VZV IgG POSITIVE mIU/mL
2025-11-05 VZV-G Value 3025.0 mIU/mL
2025-11-05 HBV DNA-PCR (quan) 137 IU/mL
2025-11-04 IgG (blood) 493 mg/dL
2025-10-31 Free Light Chain κ/λ ratio
2025-10-31 FKLC 27.95 mg/L
2025-10-31 FLLC <6.10 mg/L
2025-10-31 FK/FL ratio see comment ratio
2025-10-28 IgG (blood) 595 mg/dL
2025-10-24 Free Light Chain κ/λ ratio
2025-10-24 FKLC 57.12 mg/L
2025-10-24 FLLC 16.37 mg/L
2025-10-24 FK/FL ratio 3.49 ratio
2025-10-21 IgG (blood) 595 mg/dL
2025-10-17 Free Light Chain κ/λ ratio
2025-10-17 FKLC 111.25 mg/L
2025-10-17 FLLC 13.00 mg/L
2025-10-17 FK/FL ratio 8.56 ratio
2025-10-14 IgG (blood) 637 mg/dL
2025-09-26 CD45+Total leukocyte 188032 /uL
2025-09-26 %CD34+ 0.74 %
2025-09-26 CD34+ Count 1391 /uL
2025-09-26 CD45+Total leukocyte 29109 /uL
2025-09-26 %CD34+ 0.19 %
2025-09-26 CD34+ Count 54 /uL
2025-09-26 RPR Non-reactive
2025-09-26 HTLV 1+2 Antibody (qual) S/CO
2025-09-26 Anti HTLV I/II Nonreactive
2025-09-26 Anti HTLV I/II Value 0.07 S/CO
2025-09-26 CMV IgM Nonreactive
2025-09-26 CMV IgM Value 0.27 Index
2025-09-26 CMV_IgG Reactive
2025-09-26 CMV_IgG Value 907.9 AU/mL
2025-09-26 HIV Ab-EIA Nonreactive
2025-09-26 Anti-HIV Value 0.06 S/CO
2025-09-25 CD45+Total leukocyte 119239 /uL
2025-09-25 %CD34+ 0.34 %
2025-09-25 CD34+ Count 401 /uL
2025-09-25 CD45+Total leukocyte 9830 /uL
2025-09-25 %CD34+ 0.13 %
2025-09-25 CD34+ Count 12 /uL
2025-09-05 Free Light Chain κ/λ ratio
2025-09-05 FKLC 76.70 mg/L
2025-09-05 FLLC 8.23 mg/L
2025-09-05 FK/FL ratio 9.32 ratio
2025-09-02 IgG (blood) 529 mg/dL
2025-08-19 IgG (blood) 557 mg/dL
2025-08-19 Free Light Chain κ/λ ratio
2025-08-19 FKLC 72.57 mg/L
2025-08-19 FLLC 8.23 mg/L
2025-08-19 FK/FL ratio 8.82 ratio
2025-08-01 Free Light Chain κ/λ ratio
2025-08-01 FKLC 87.71 mg/L
2025-08-01 FLLC 8.59 mg/L
2025-08-01 FK/FL ratio 10.21 ratio
2025-07-29 IgG (blood) 644 mg/dL
2025-07-18 Free Light Chain κ/λ ratio
2025-07-18 FKLC 124.78 mg/L
2025-07-18 FLLC 9.58 mg/L
2025-07-18 FK/FL ratio 13.03 ratio
2025-07-15 IgG (blood) 815 mg/dL
2025-07-08 IgG (blood) 863 mg/dL
2025-07-04 Free Light Chain κ/λ ratio
2025-07-04 FKLC 293.11 mg/L
2025-07-04 FLLC 11.97 mg/L
2025-07-04 FK/FL ratio 24.49 ratio
2025-07-01 IgG (blood) 1187 mg/dL
2025-06-20 Free Light Chain κ/λ ratio
2025-06-20 FKLC 607.04 mg/L
2025-06-20 FLLC 12.68 mg/L
2025-06-20 FK/FL ratio 47.87 ratio
2025-06-16 IgG (blood) 1900 mg/dL
2025-06-02 Free Light Chain κ/λ ratio
2025-06-02 FKLC 2742.18 mg/L
2025-06-02 FLLC 19.90 mg/L
2025-06-02 FK/FL ratio 137.80 ratio
2025-05-27 IgG (blood) 4520 mg/dL
2025-05-23 Free Light Chain κ/λ ratio
2025-05-23 FKLC 5352.59 mg/L
2025-05-23 FLLC 20.07 mg/L
2025-05-23 FK/FL ratio 266.70 ratio
2025-05-22 Bone Marrow Chromosome Analysis
2025-05-20 IgG (blood) 5614 mg/dL
2025-05-10 Protein EP
2025-05-10 Protein, total 10.6 g/dL
2025-05-10 Albumin 33.3 %
2025-05-10 Alpha-1 2.8 %
2025-05-10 Alpha-2 8.5 %
2025-05-10 Beta 7.5 %
2025-05-10 Gamma 47.9 %
2025-05-10 M-peak Positive
2025-05-10 A/G Ratio 0.50
2025-05-10 Protein, total 10.5 g/dL
2025-05-10 Albumin 33.3 %
2025-05-10 Alpha-1 2.8 %
2025-05-10 Alpha-2 8.5 %
2025-05-10 Beta 7.5 %
2025-05-10 Gamma 47.9 %
2025-05-10 M-peak Positive
2025-05-10 A/G Ratio 0.50
2025-05-10 IgG/A/M Kappa/Lambda IgG + Kappa chain
2025-05-09 Free Light Chain κ/λ ratio
2025-05-09 FKLC 5347.56 mg/L
2025-05-09 FLLC 13.34 mg/L
2025-05-09 FK/FL ratio 400.87 ratio
2025-05-07 B2-Microglobulin 3028 ng/mL
2025-05-07 Bone marrow cell morphology interpretation combined with
differential cell count
2025-05-07 Age/Sex 63/M
2025-05-07 Clinical information AG reverse, suspected M
2025-05-07 Cellularity Hyper.
2025-05-07 M/E ratio 3/1
2025-05-07 Myelo.Blast 0 %
2025-05-07 Myelo.Pro. 0 %
2025-05-07 Myelo.Myelo. 1 %
2025-05-07 Myelo.Meta. 6 %
2025-05-07 Myelo.Band. 5 %
2025-05-07 Myelo.Seg. 18 %
2025-05-07 Lymphoid series 0 %
2025-05-07 Monocyte 0 %
2025-05-07 Plasma cell 60%
2025-05-07 Megakaryocyte 0-2 LPF
2025-05-07 Ery.Pronormo. 0 %
2025-05-07 Ery.Nor.Basophilic 0 %
2025-05-07 Ery.Nor.Poly. 3 %
2025-05-07 Ery.Nor.Ortho. 7 %
2025-05-07 MPO na
2025-05-07 CAE na
2025-05-07 ANAE na
2025-05-06 IgG (blood) 6529 mg/dL
2025-05-06 IgM <20 mg/dL
2025-05-06 IgA 15 mg/dL
2025-05-06 HBsAg Reactive
2025-05-06 HBsAg Value 4335.34 S/CO
2025-05-06 Anti-HBs 0.00 mIU/mL
2025-05-06 Anti-HCV Nonreactive
2025-05-06 Anti-HCV Value 0.06 S/CO
2025-05-06 Anti-HBc Reactive
2025-05-06 Anti-HBc Value 5.61 S/CO
2025-05-05 Reticulocyte count 2.490 %
[exam finding]
2025-11-04 ECG
2025-11-04 CXR
2025-06-10 ECG
2025-06-10 Lung Function Test
2025-06-09 CXR
2025-05-06 Pathology - bone marrow biopsy
[MedRec]
2025-12-15 Family Meeting - conditioning regimen
2025-11-11 SOAP Hemato-Oncology He JingLiang
2025-11-04 ~ 2025-11-04 POMR Hemato-Oncology He JingLiang
2025-09-14 ~ 2025-09-26 POMR Hemato-Oncology Liu YiSheng
2025-05-20 SOAP Hemato-Oncology He JingLiang
2025-05-09 SOAP Hemato-Oncology Yang MuJun
2025-05-05 ~ 2025-05-06 POMR Hemato-Oncology He JingLiang
2025-05-02 SOAP Hemato-Oncology Yang MuJun
[chemotherapy]
2025-11-11 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-11-04 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD)
2025-10-28 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-10-21 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD)
2025-10-14 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-09-15 - mesna 300mg/m2 540mg NS 100mL 15min (before Endoxan) + cyclophosphamide 1500mg/m2 2740mg NS 500mL 1hr + NS 500mL 1hr (after Endoxan) + mesna 600mg/m2 1100mg NS 100mL 15min (4 hrs after Endoxan) + NS 500mL 1hr + mesna 600mg/m2 1100mg NS 100mL 15min (8 hrs after Endoxan) + NS 500mL 1hr
2025-08-19 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD)
2025-08-12 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-08-05 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD)
2025-07-29 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-07-22 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD)
2025-07-15 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-07-08 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD)
2025-07-01 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-06-24 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 400mg NS 480mL 3.5hr (VTD, Darzalex reduced to 400mg for ANC 918)
2025-06-17 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-06-10 - montelukast 10mg PO + bortezomib 1.3mg/m2 2.3mg SC 3min + daratumumab 16mg/kg 800mg NS 480mL 3.5hr (VTD)
2025-05-30 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-05-27 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-05-23 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
2025-05-20 - bortezomib 1.3mg/m2 2.3mg SC 3min (VTD)
[medication]
Thado (thalidomide 50mg) 2# HS
Limeson (dexamethasone 4mg) 5# QD
Xgeva (denosumab) 120mg SC
Key Insights/Summary
Problem 1. Autologous stem cell transplant admission and peri-transplant readiness (planned auto-SCT with reinfusion rescue)
Problem 2. Multiple myeloma, IgG kappa, post-induction response status and relapse surveillance
Problem 3. Infection risk management in the peri-transplant setting (bacterial, fungal, viral; neutropenia preparedness)
Problem 4. Hepatitis B infection status and antiviral prophylaxis during immunosuppression
Problem 5. Myeloma-associated bone disease and skeletal risk (vertebral compression fracture history; suspected rib lesions)
Problem 6. Cardiac conduction abnormalities and transplant cardiotoxicity risk
Problem 7. Pulmonary function reserve and peri-transplant respiratory risk
Problem 8. Current medications, supportive care, and anticipated complications (mucositis, GI protection, BPH, transfusion planning)
[exam finding]
2025-11-27 Sigmoidscopy
2025-09-26 Pathology - colon biopsy
2025-09-26 Colonoscopy
2025-09-25 PET
2025-09-24 MRI - pelvis
2025-09-22 CT - abdomen
2025-09-22 Pathology
[MedRec]
2025-11-24 SOAP Colorectal Surgery Xiao GuangHong
2025-10-12 ~ 2025-10-17 POMR Hemato-Oncology Yang MuJun
2025-10-03 SOAP Hemato-Oncology Yang MuJun
[radiotherapy]
[chemotherapy]
Key Insights/Summary
Problem 1. Locally advanced rectosigmoid junction adenocarcinoma on total neoadjuvant therapy pathway, post-CCRT with ongoing neoadjuvant FOLFOX
Problem 2. Chemotherapy and radiotherapy tolerance, toxicity surveillance, and supportive care during FOLFOX
Problem 3. Hepatitis B core antibody positivity with risk of HBV reactivation during chemotherapy
Problem 4. Electrolyte and metabolic issues: borderline hypocalcemia, prior hypomagnesemia, and obesity
Problem 5. Grade 4 fatty liver with intermittent mild transaminitis during systemic therapy
Problem 6. Urticaria and allergy-risk context during chemotherapy and supportive medications
[exam finding]
2025-12-08 KUB
2025-12-08, 2025-12-01, 2025-11-27 CXR
2025-11-25 Percutaneous Transhepatic Cholangial Drainage, PTCD
2025-11-21 Cell block cytology - pleural effusion
2025-11-21 Neck Soft Tissue
2025-11-20, 2025-11-18, 2025-11-14, 2025-11-10, 2025-11-05 CXR
2025-11-18 Endoscopic Retrograde Cholangiopancreatography, ERCP
2025-11-14 Cystoscopy
2025-11-11 CT - abdomen
2025-11-10 Sonography - abdomen
2025-11-04 CT - chest
2025-11-02 CXR semierect view
2025-11-01 CXR
2025-11-01 ECG
2024-10-16 Tc-99m MDP bone scan
2024-08-17 CT - chest
2024-03-20 Tc-99m MDP bone scan
2024-03-16 CT - chest
2024-03-12 Sonography - abdomen
2024-02-15 KUB + L-spine Lat
2023-12-06 PET
2023-12-05 CT - chest
2018-05-07 Knee Rt standing
2018-05-07 Knee Lt standing
2018-05-07 Merchant view (patella 45 0) Bil
[MedRec]
2024-11-06 SOAP Radiation Oncology Huang JingMin
2024-03-28 ~ 2024-03-30 POMR Hemato-Oncology Gao WeiYao
[radiotherapy]
[chemotherapy]
[exam findings]
2025-11-03 Sonography - gynecology
2025-10-30 Microsonography
2025-10-08 Sonography - urology
2025-09-28 CXR
2025-09-15 CT - abdomen
2025-08-06 Sonography - gynecology
2025-07-16 KUB
2025-06-07 CT - chest
2025-06-06 Tc-99m MDP bone scan
2025-05-09 Sonography - gynecology
2025-03-22 CT - abdomen
2025-03-21 CXR
2025-02-17 Papanicolaou test (Pap smear)
2025-02-14 Sonography - gynecology
2024-12-05 CT - abdomen
2024-12-03 Abdomen - standing (diaphragm)
2024-11-26 Pathology - cervix biopsy
2024-11-26 Pathology - endocervix curettage/biopsy
2024-11-15 Tc-99m MDP bone scan
2024-11-14 MRI - pelvis
2024-11-13 T-L spine AP + Lat
2024-11-04 Papanicolaou test (Pap smear)
2024-10-21 Transesophageal echocardiography
2024-10-21 Sonography - gynecology
2024-10-18 Lung Function Test
2024-09-22 ECG
2024-08-30 CT - abdomen
2024-07-18 RAS + BRAF V600
2024-07-17 PET
2024-07-15 SONO - neck (lymph node)
2024-07-12 CT - neck
2024-06-22 ECG
2024-05-23 KUB
2024-05-07 CT - chest
2024-04-25 Pathology - omentum biopsy
2024-04-25 Pathology - peritoneum biopsy
2024-03-27 CT - abdomen
[MedRec]
2025-11-19 ~ 2025-11-22 POMR Hemato-Oncology Yang MuJun
2025-09-28 ~ 2025-10-01 POMR Urology Xu JunKai
2025-07-31 SOAP Ophthalmology Wu LiLi
2024-05-23 ~ 2024-05-27 POMR Integrative Medicine Yang MuJun
2024-04-24 ~ 2024-04-29 POMR General and Gastrointestinal Surgery Chen YanZhi
2022-07-06 ~ 2022-07-08 POMR Ophthalmology Wu LiLi
2021-03-09 ~ 2021-03-16 POMR Ophthalmology Wu LiLi
[consultation]
2024-12-24 Ophthalmology
2024-12-02 Obstetrics and Gynecology
2024-10-21 Obstetrics and Gynecology
2024-09-02 General and Gastroenterological Surgery
2024-07-18 General and Gastroenterological Surgery
[surgical operation]
2025-09-29
2025-01-09
2024-09-04
2024-05-15
2024-04-25
2024-03-13
2022-07-06
2021-08-11
2021-03-10
[chemotherapy]
[Subjective]
FOLFIRI tolerance and atropine adjustment
Appetite, mobility, and general condition
Blood pressure self-monitoring
[Objective]
Chemotherapy and premedication
Medications
Active antihypertensive: Norvasc (amlodipine) 5mg QD No scheduled antidiarrheal premedication (e.g., atropine or loperamide)
[Assessment]
Irinotecan-related cholinergic syndrome risk management
Blood pressure control
Nutritional and performance status
[Plan / Recommendation]
Atropine adjustment for future FOLFIRI
Antidiarrheal contingency
Blood pressure monitoring
Supportive care
Key insights / summary
Problem 1. Pseudomyxoma peritonei / mucinous carcinoma peritonei, low grade, cTxNxM1, stage IV, peritoneal-dominant with progressive carcinomatosis
Problem 2. Large pelvic / left adnexal cystic mass with progressive enlargement and ascites
Problem 3. Bilateral hydronephrosis and hydroureters due to external compression, status post bilateral ureteral tumor stents with preserved renal function
Problem 4. Chronic hepatitis B infection under antiviral prophylaxis during prolonged chemotherapy
Problem 5. Gastrointestinal symptoms related to chemotherapy (constipation and intermittent mild diarrhea) and Barrett’s esophagus
Problem 6. Hematologic status: mild normocytic anemia; adequate leukocytes and platelets
Problem 7. Ophthalmologic comorbidities: bilateral retinal detachment and macular hole with multiple surgeries; current visual impairment
Problem 8. Cardiometabolic and general organ function: hypertension, fatty liver, preserved cardiac and pulmonary function
Problem 9. Electrolyte and metabolic status: currently stable
Overall, the patient remains functionally preserved with stable organ systems, but her peritoneal malignancy is slowly progressive despite extensive chemotherapy. The main focus should be on carefully balancing additional systemic therapy (including potential biologic agents or trial options) with vigilant management of renal, hepatic, and cardiovascular health, and on proactive palliation of emerging symptoms from the expanding pelvic mass and ascites.
This is a 64-year-old woman with low-grade pseudomyxoma peritonei (stage IV) who is receiving FOLFIRI chemotherapy (irinotecan, leucovorin, fluorouracil) with irinotecan dose reduced (85% on 2025-07-16). She has persistently elevated CEA and CA19-9, suggesting ongoing disease activity. Despite chemotherapy, tumor markers remain elevated, indicating partial or suboptimal response. Liver and renal functions are preserved (eGFR 89.8, Cr 0.70, AST/ALT <15), and she is hemodynamically stable. Supportive medications include Baraclude (entecavir) for HBV, analgesics, and GI prophylaxis. No major acute complications observed during chemotherapy.
Problem 1. Persistent tumor marker elevation (CEA, CA19-9) under chemotherapy (not posted)
Problem 2. Chemotherapy regimen and tolerability (FOLFIRI)
Problem 3. Liver and renal function under chemotherapy (not posted)
Problem 4. Pain and symptom control (not posted)
Problem 5. Cardiovascular status and antihypertensive management (not posted)
The patient has unresectable, low-grade pseudomyxoma peritonei (PMP) confirmed on pathology (2024-04-25), with disease progression noted on recent CT (2025-06-07) showing enlargement of pelvic cystic lesion (from 10.7 cm to 13.03 cm) and worsening cancerous peritonitis. She had previously completed multiple cycles of systemic (modified FOLFOX6 and 5-FU) and intraperitoneal chemotherapy (IP 5-FU), achieving temporary disease control. However, due to radiologic progression and rising CEA/CA19-9 levels, she was shifted to FOLFIRI regimen starting on 2025-06-19.
Her performance status remains preserved (ECOG 1), with stable hemodynamics and tolerable side effects from the new chemotherapy regimen. There is no hepatic, renal, or hematologic toxicity at present. No evidence of metastases on bone scan (2025-06-06). Mild right-sided costovertebral angle tenderness may reflect hydronephrosis or chronic renal scarring. She remains functionally stable.
Problem 1. Pseudomyxoma peritonei (mucinous carcinoma peritonei), in progression
Problem 2. Hematologic status under chemotherapy
Problem 3. Hepatorenal function and electrolyte status
Problem 4. Gastrointestinal tolerance and chemotherapy side effects
This is a 64-year-old woman with low-grade pseudomyxoma peritonei (PMP), diagnosed via laparoscopy and biopsy on 2024-04-25, presenting as stage IV (cTxNxM1) mucinous carcinoma peritonei. The disease is deemed unresectable, with cytoreductive surgery and HIPEC not suitable due to extensive peritoneal seeding (PCI 29/39 on 2024-09-04). She has since undergone systemic chemotherapy with modified FOLFOX6 and intraperitoneal 5-FU, showing stable disease on serial imaging (CT 2025-03-22).
Recent tumor markers (CEA/CA19-9) show stabilization or mild fluctuation after prior elevation. Vital signs are stable, and no current evidence of end-organ damage or treatment-limiting toxicity. Current therapy appears tolerable and aligned with disease biology and clinical course.
Problem 1. Low-grade pseudomyxoma peritonei (mucinous carcinoma peritonei)
Problem 2. Hematologic tolerance to chemotherapy
Problem 3. Hepatic and renal function during chemotherapy
Problem 4. Cardiopulmonary monitoring and performance status
[Pseudomyxoma Peritonei: Stable Disease and Improving Liver Function]
Lab results indicate improvement in liver function, with ALT and AST levels returning toward the normal range.
2024-09-19 ALT 38 U/L
2024-09-13 ALT 46 U/L
2024-09-05 ALT 67 U/L
2024-09-19 AST 46 U/L
2024-09-13 AST 53 U/L
2024-09-05 AST 73 U/L
The CT scan (2024-08-30) shows stable carcinomatosis (pseudomyxoma peritonei) compared to the prior scan from 2024-03-27, following chemotherapy.
CEA and CA199 levels have remained relatively stable at 15-20 ng/mL and 300-350 U/mL, respectively, suggesting stable disease.
2024-08-29 CEA 15.41 ng/mL
2024-07-12 CEA 20.97 ng/mL
2024-06-24 CEA 18.55 ng/mL
2024-04-24 CEA 23.27 ng/mL
2024-03-11 CEA 19.14 ng/mL
2024-02-17 CEA 15.01 ng/mL
2024-01-09 CEA 26.36 ng/mL
2024-08-29 CA199 285.93 U/mL
2024-07-12 CA199 352.43 U/mL
2024-06-24 CA199 358.44 U/mL
2024-04-24 CA199 364.88 U/mL
2024-03-11 CA199 346.21 U/mL
2024-02-17 CA199 299.32 U/mL
2024-01-09 CA199 422.77 U/mL
No medication issues were identified.
[normal lab results clear for FOLFOX regimen administration]
Lab results on 2024-06-03 showed no significant abnormalities.
These normal results allow for the planned FOLFOX regimen to proceed without contraindication.
Additionally, no discrepancies were found in the patient’s medication list.
[exam findings]
2025-11-14 PD-L1 (22C3)
2025-11-14 Pure Tone Audiometry, PTA
2025-10-27 PET
2025-10-16 CT - neck
2025-10-16 Nasopharyngoscopy
2025-08-26 Swallowing video fluoroscopy
2025-08-26 Swallowing Assessment
2025-07-24 Pathology - gingival/oral mucosa biopsy
2025-07-17 Sonography - abdomen
2025-07-11 CT - facial bone
2025-07-04 MRI - nasopharynx
2025-02-06 Nasopharyngoscopy
2025-01-20 Pathology - oral cancer (wide excision without lymph node)
2025-01-20 CXR
2025-01-17 Frozen Section
2025-01-10 Pathology - gallbladder (benign lesion)
Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis
2024-12-31 PET
2024-12-12 MRI - nasopharynx
2024-12-04 - Retrograde cholangiopancreatography
2024-12-03 MR Cholangiography, MRCP
2024-12-03 T-tube cholangiography
2024-11-29 Percutaneous Gall Bladder Drainage, PTGBD
2024-11-28 CT - abdomen
2024-08-22 Nasopharyngoscopy
2024-07-13 Nasopharyngoscopy
2024-07-10 Patho - oral cancer (wide excision + lymph node)
2024-07-03 Tc-99m MDP bone scan
2024-07-03 Patho - stomach biopsy
2024-07-02 Patho - gingival/oral mucosa biopsy
2024-07-02 Esophagogastroduodenoscopy, EGD
2024-07-01 CT - neck
2024-07-01 SONO - abdomen
2023-02-20 SONO - abdomen
2022-11-30 Patho - seborrheic keratosis
2022-03-22 Colonoscopy
2021-03-18 Patho - soft tissue lipoma
2021-03-18 SONO - abdomen
2019-10-29 Surgical pathology Level IV
2019-10-29 SONO - abdomen
2018-09-15 CT - abdomen
[MedRec]
2025-11-13 ~ 2025-11-24 POMR Hemato-Oncology Xia HeXiong
2025-07-22 ~ 2025-08-16 POMR Oral and Maxillofacial Surgery Xu BoZhi
2024-07-22 SOAP Radiation Oncology Wang YuNong
2024-07-08 ~ 2024-07-12 POMR Ear Nose Throat Su WangYu
2015-08-11 ~ 2015-08-17 POMR Colorectal Surgery Xiao GuangHong
[surgical operation]
2025-07-30
2025-01-17
2025-01-10
2024-07-23
2024-07-09
2023-09-11
2022-11-30
2021-03-18
2018-10-19
2017-03-07
[radiotherapy]
[chemotherapy]
UFT (tegafur 100mg, uracil 224mg) 2# BID
Vemlidy (tenofovir alafenamide 25mg) 1# QD
Key insights / summary
Problem 1. Recurrent, unresectable and likely metastatic right tongue squamous cell carcinoma under PF4 chemotherapy with planned pembrolizumab
Problem 2. Cancer-related pain (neck and bilateral shoulders) and overall symptom control
Problem 3. Nutritional compromise, dysphagia and long-term NG-tube dependence
Problem 4. Suspected ongoing infection / inflammatory activity in context of previous jaw wound infection
Problem 5. Chronic microcytic anemia and hematologic status under chemotherapy
Problem 6. Electrolyte disturbances (hyponatremia) and organ function
Problem 7. Chronic viral hepatitis B under chemotherapy and planned immunotherapy
Problem 8. History of sigmoid colon cancer and other second primary malignancies
Overall, the current priorities are to optimize systemic pembrolizumab + PF4 therapy in alignment with guidelines, control pain and infection, support nutrition, and carefully monitor organ function and HBV status to maintain treatment feasibility while preserving quality of life.
[Vemlidy Tube-Feeding Methods and G-CSF Prescribed for Neutropenia]
Vemlidy (tenofovir alafenamide) can be administered via feeding tube, either by splitting the tablet, crushing it, or using the simple suspension method (SSM).
Neutropenia was observed today, and a 3-day course of G-CSF (filgrastim) has been prescribed. No medication issues were identified.
2024-09-18 WBC 1.42 x10^3/uL
2024-09-18 WBC 1.57 x10^3/uL
2024-09-10 WBC 2.69 x10^3/uL
2024-09-02 WBC 3.93 x10^3/uL
2024-08-26 WBC 4.77 x10^3/uL
2024-08-19 WBC 7.59 x10^3/uL
2024-09-18 Neutrophil 58.9 %
2024-09-18 Neutrophil 56.1 %
2024-09-10 Neutrophil 75.8 %
2024-09-02 Neutrophil 72.5 %
2024-08-26 Neutrophil 79.1 %
2024-08-19 Neutrophil 80.3 %
[cisplatin and worsening renal function]
The patient’s serum creatinine levels have been steadily increasing over the past month. While the current cisplatin dose, administered as part of concurrent chemoradiotherapy, is not exceptionally high, however it is recommended to consider temporarily suspending cisplatin if there is evidence of a rapid decline in renal function.
[lab data]
2025-09-29 Testosterone 18.71 ng/dL
2025-07-08 Testosterone 18.99 ng/dL
2025-09-29 PSA 0.016 ng/mL
2025-07-08 PSA 5.524 ng/mL
2025-03-17 PSA 8.429 ng/mL
2025-02-24 PSA 7.871 ng/mL
2025-02-04 Free PSA 1.006 ng/mL
2025-02-04 free PSA/PSA 16.217 %
2025-02-04 PSA 6.204 ng/mL
2024-07-02 PSA 5.869 ng/mL
2024-01-09 Free PSA 0.763 ng/mL
2024-01-09 free PSA/PSA 10.723 %
2024-01-09 PSA 7.117 ng/mL
2023-11-24 PSA 6.778 ng/mL
2023-03-28 PSA 6.987 ng/mL
[exam finding]
2025-05-09 MRI - prostate
2025-04-17 Tc-99m MDP bone scan
2025-03-18 Pathology - prostate needle biopsy
2025-03-18 Pathology - prostate needle biopsy
2025-03-17 Transrectal Ultrasound of Prostate, TRUS-P
2025-01-17 Neurosonography
2024-07-29 Mini-Mental State Examination
2024-07-29 Clinical Dementia Rating, CDR
2024-04-19 Hearing Test
2024-03-13 MRA - brain
[MedRec]
2025-12-01 SOAP Neurology Xu BoRen
2025-10-13 SOAP Urology Xu JunKai
2025-07-23 ~ 2025-07-28 POMR Urology Xu JunKai
2024-02-04 ~ 2024-02-07 POMR Integrative Medicine Yang MuJun
[radiotherapy]
[medication]
Zoladex LA Depot (goserelin) 10.8mg IVD
Firmagon (degarelix) 80mg SC
20251210 與病人兒子通話 (因為病人本身聽力不好, 且有輕微認知障礙), 叮嚀病人就診時,詢問醫師是否要追蹤潛在可能的骨轉移,此外由於之前的 UTI 且服用 forxiga, 如若發現小便有灼熱或疼痛感,可先停用病就診請醫師確認。
[Subjective]
Contact with caregiver (2025-12-10)
Symptoms as reported via son
[Objective]
Prostate cancer and skeletal concern
Recurrent UTI history and recent episode
Current medications relevant to this note (2025-12-01 neurology SOAP and 2025-10-13 urology SOAP)
Patient factors affecting communication and adherence
[Assessment]
Need for clear follow-up on potential bone metastasis vs degenerative disease
Risk–benefit evaluation of Forxiga (dapagliflozin) in the context of recurrent UTI
Suitability of caregiver-centered education approach
Potential areas for improvement
[Plan / Recommendation]
Enhance oncologic follow-up for skeletal status
Refined guidance for Forxiga (dapagliflozin) use in the context of UTI risk
Coordinate diabetes regimen review with primary physician/endocrinology
Communication and education strategy
Documentation and interprofessional communication
Key insights / Summary
Problem 1. Localized prostate adenocarcinoma status post definitive RT + ADT
Problem 2. Androgen deprivation therapy (ADT) monitoring and long-term toxicity
Problem 3. Recurrent urinary tract infection (UTI) in an elderly diabetic male with prostate cancer
Problem 4. Type 2 diabetes mellitus and cardiometabolic risk under ADT and aging
Problem 5. Mild dementia / cognitive impairment with vascular contributions
Problem 6. Hearing loss (right mild-to-severe SNHL, left profound SNHL)
Problem 7. Overall organ function and hematologic status in the context of multimorbidity and cancer therapy
Mini-Mental State Examination & Clinical Dementia Rating
[exam finding] (not completed)
2024-12-07 Sonography - urology
2023-10-02 MRI - prostate
2023-09-19 Tc-99m MDP bone scan
2023-09-01 Pathology - prostate needle biopsy
2023-09-01 Pathology - prostate needle biopsy
2023-08-18 Transrectal Ultrasound of Prostate, TRUS-P
[MedRec]
2025-11-29 SOAP Urology Guo HanChong
2023-11-14 SOAP Radiation Oncology Huang JingMin
[exam finding]
2025-12-03 Sonography - chest
2025-12-02 CXR
2025-12-02 Sonography - abdomen
2025-12-01 Tc-99m MDP bone scan
2025-12-01 Sonography - nephrology
2025-11-30 CXR
2025-11-30 KUB
2025-11-28 Pathology - bone marrow biopsy
2025-11-28 Lung Function Test
2025-11-28 2D transthoracic echocardiography
2025-11-27 Sonography - kidney
2025-11-26 PET
2025-11-24 ECG
2025-10-30 CT - abdomen
2025-07-25 LDCT without contrast
2025-07-17 Sonography - abdomen
2025-04-07 Sonography - abdomen
2025-01-13 Sonography - abdomen
2024-08-29 Bone densitometry - spine
….-..-..
2020-10-27 Pathology - breast mastectomy with regional lymph nodes
2020-10-26 Sonography - abdomen
2020-10-21 Tc-99m MDP bone scan
[MedRec]
2025-12-04 MultiTeam - Psycho-oncology
2025-11-21 ~ 2025-12-05 POMR Hemato-Oncology Yang MuJun
2025-11-03, 2025-07-23, 2025-04-14, 2025-01-20 SOAP General and Gastroenterological Surgery Zhang YaoRen
2020-11-09 ~ 2020-11-11 POMR General and Gastroenterological Surgery Zhang YaoRen
2020-10-26 ~ 2020-10-30 POMR General and Gastroenterological Surgery Zhang YaoRen
[surgical operation]
2020-10-27
[radiotherapy]
[chemotherapy]
[medication]
Femara (letrozole 2.5mg) 1# QD
[exam finding]
2025-10-30 2D transthoracic echocardiography
2025-07-31 Sonography - abdomen
2025-07-28, 2024-12-17 CXR
2024-04-22 Pathology - bone marrow biopsy
2024-11-29 Pathology - bone marrow biopsy
2024-08-22, 2024-04-15 CXR
2024-07-23 Pathology - bone marrow biopsy
2023-11-06 Pathology - bone marrow biopsy
2023-11-03 Sonography - abdomen
2023-11-02 CXR
2023-10-19 Pathology
2023-10-18 Esophagogastroduodenoscopy, EGD
2023-10-18 Colonoscopy
2023-09-09 CXR
2023-07-10 CXR
2023-06-20 Pathology - bone marrow biopsy
2023-06-20 Anoscopy
2023-06-15 Pathology - stomach biopsy
2023-06-15 Esophagogastroduodenoscopy, EGD
2023-06-09 CXR
2023-06-09 Sonography - abdomen
2023-04-08 CT
2022-12-15 2D transthoracic echocardiography
2022-09-05 CT - temporal bone HRCT
2022-08-01 Hearing Test
[MedRec]
2025-11-25, 2025-09-02, 2025-06-02 SOAP Rheumatology and Immunology Chen ZhengHong
2025-10-28 ~ 2023-11-03 POMR Hemato-Oncology Gao WeiYao
2023-11-02 ~ 2023-11-06 POMR Hemato-Oncology Gao WeiYao
2023-03-13 ~ 2023-03-15 POMR Rheumatology and Immunology Chen ZhengHong
[chemotherapy]
[medication]
[Differential diagnosis] (from most to least likely, based on labs alone)
Chronic myelomonocytic leukemia (CMML) / MDS-MPN overlap (clonal myeloid neoplasm)
Myelodysplastic syndrome (MDS) with multilineage dysplasia / clonal cytopenia (MDS spectrum distinct from but related to CMML)
Autoimmune/connective tissue disease–associated cytopenias and monocytosis (e.g., Sjögren’s/SLE overlap with immune-mediated cytopenias)
Reactive monocytosis from chronic or subacute infection/inflammation (including urinary tract source)
Drug-induced bone marrow suppression / cytopenias
Summary
Key insights / summary (2025-12-08)
Problem 1. Chronic myelomonocytic leukemia not in remission under long-term Vidaza
Problem 2. Infection risk and current antimicrobial management during Vidaza therapy
Problem 3. Chronic hepatitis B under immunosuppressive therapy and hepatic cysts
Problem 4. Splenomegaly and hematologic consequences
Problem 5. Cardiovascular status and suitability for ongoing chemotherapy
Problem 6. Sjogren syndrome, chronic pain, and quality-of-life management
[Medication/treatment-related issues to be concerned] (2025-12-08)
Vidaza (azacitidine) repeated cycles in CMML
Broad-spectrum Tapimycin (piperacillin/tazobactam) IV Q6H
Infection prophylaxis gaps during hypomethylating therapy
Ocular steroid burden and polypharmacy
Long-term Plaquenil (hydroxychloroquine) therapy
CNS/anticholinergic burden from Pilian (cyproheptadine) and other agents
Acetal (acetaminophen) PRN and masking of fever
Baraclude (entecavir) prophylaxis for chronic HBV during chemotherapy
[exam finding]
2025-11-20 CXR
2025-11-18 2D transthoracic echocardiography
2025-11-17 Bronchodilator Test, BDT
2025-11-07 Surgical Pathology Level III
2025-10-31 CT
2025-10-30 MRI - brain
2025-10-17 Pap’s Smear
2025-07-30 MRI - brain
2020-07-06 CT
2020-04-30 MRI - brain
[MedRec]
2025-12-01 SOAP Radiation Oncology Chang YouKang
2025-11-17 SOAP Hemato-Oncology Lin YiTing
2025-11-11 SOAP Plastic and Reconstructive Surgery Lu ChunDe
2016-05-11 ~ 2016-05-14 POMR
2016-04-06 ~ 2016-04-12 POMR
[surgical operation]
2025-11-20
2025-11-06
Key insights / summary
Problem 1. Metastatic angiosarcoma of scalp with right perineal/vulvar metastasis under palliative RT + paclitaxel and Propranolol
Problem 2. Cardiovascular disease and diastolic dysfunction under cancer therapy
Problem 3. Obstructive airway disease and pulmonary risk under non-selective beta-blocker and chemotherapy
Problem 4. Autoimmune/connective tissue disease and chronic rash under multi-drug immunomodulatory and antihistamine therapy
Problem 5. Infection risk and wound healing (scalp wound, Port-A catheter, systemic immunosuppression)
Problem 6. Hepatitis B core antibody positivity on Tenofovir alafenamide prophylaxis during immunosuppressive therapy
Problem 7. Hyperuricemia on Febuxostat in a patient with CAD
Problem 8. Baseline hematologic status and risk of chemotherapy-induced myelosuppression
Problem 9. Metabolic and lifestyle risk factors: obesity and hyperlipidemia
[lab data]
2025-10-16 EB VCA IgG Positive Ratio
2025-10-16 EB VCA IgG Value 4.9 Ratio
2025-10-14 RPR Non-reactive
2025-10-13 VZV IgG POSITIVE mIU/mL
2025-10-13 VZV-G Value 1632 mIU/mL
2025-10-13 EB VCA IgM NEGATIVE U/mL
2025-10-13 EB VCA IgM Value <10.0 U/mL
2025-10-13 CMV_IgG Reactive
2025-10-13 CMV_IgG Value 182.2 AU/mL
2025-10-13 CMV IgM Nonreactive
2025-10-13 CMV IgM Value 0.42 Index
2025-10-13 Anti HTLV I/II Nonreactive
2025-10-13 Anti HTLV I/II Value 0.07 S/CO
2025-10-13 HIV Ab-EIA Nonreactive
2025-10-13 Anti-HIV Value 0.05 S/CO
[exam finding]
[MedRec]
2025-10-20 10:45 Family Meeting - Conditioning Regimen
[consultation]
2025-11-18 Infectious Disease
[surgical operation]
2025-11-18
2025-07-08
2024-04-21
2021-04-09
[radiotherapy]
[chemotherapy]
[note]
Non-Hodgkin lymphoma ESHAP (etoposide methylprednisolone cytarabine ciSplatin) - 2025-10-14 - https://www.eviq.org.au/haematology-and-bmt/lymphoma/other-b-cell-lymphoma/124-eshap-etoposide-methylprednisolone-cytarabine
Chemotherapy regimen: ESHAP - 2025-10-14 - https://hivclinic.ca/main/drugs_chemo_files/ESHAP.pdf
Problem 1. Severe chemotherapy-induced neutropenia and infection management
Problem 2. Chemotherapy-induced thrombocytopenia and anemia with transfusion support
Problem 3. Gastrointestinal toxicity, diarrhea, and use of antimotility agents and PPIs
Problem 4. Organ toxicity monitoring after high-dose Busulfan/Etoposide/Endoxan and Mesna
Problem 5. Polypharmacy, overlapping coverage, and supportive medications
note for Problem 5 [cefepime + teicoplanin + fluconazole]
Key insights / summary
Problem 1. Profound post-PBSCT pancytopenia with severe neutropenia and thrombocytopenia
Problem 2. Neutropenic fever / probable sepsis under broad-spectrum antibiotics
Problem 3. Chemotherapy-related gastrointestinal toxicity and fluid balance
Problem 4. Central venous catheter management and infection prevention under intensive therapy
Problem 5. Organ function and electrolyte monitoring under high-dose chemotherapy and multi-drug regimen
Key Insight / Summary
Problem 1. Conditioning Chemotherapy Toxicity Risk (Busulfan–Etoposide–Cyclophosphamide)
Problem 2. Drug–Drug Interactions in Conditioning Regimen (Phenytoin–Busulfan, Fluconazole–Busulfan)
Problem 3. Hematological Suppression (Anemia, Neutropenia Trend)
Problem 4. Electrolyte Abnormalities (Hypokalemia, Low–normal Calcium)
Problem 5. Infection Prophylaxis and Risk Post Tooth Extraction
Problem 6. Fluid–Line Access Management (Port-A + RIJV Permcath)
Problem 7. Gastrointestinal Toxicity (Nausea, Constipation)
Problem 8. Ocular Dryness Post Chemotherapy
[bedside visit]
On 2025-10-20, at 11:45 AM, following the Family Meeting and Interprofessional Practice (IPP) Meeting held that morning, I went to the patient’s room. During the recently concluded meeting, the patient seemed somewhat hesitant about the need to undergo chemotherapy again as part of the transplant process. Therefore, I intended to further understand the reasons for his hesitation and attempt to address his concerns.
The patient, his wife, and his son (who was participating via video conference from the United States, where he has a 9-month-old child) were all present in the room. I inquired about his past chemotherapy experiences. The patient indicated that he had experienced nausea, vomiting, and fatigue. I informed the patient that the antiemetic agents being used for the current hospitalization’s chemotherapy were more potent than those used previously. The patient confirmed that the feeling of nausea did seem to be milder this time.
Regarding the upcoming autologous hematopoietic stem cell transplant, I explained to the patient that a more thorough conditioning (clearance) of the bone marrow is necessary to ensure a good environment for the engrafted stem cells and to minimize the chance of recurrence. I advised the patient to be mentally prepared to be extremely diligent with infection prevention measures during that period. The patient and his family confirmed their understanding.
Key Insights/Summary (2025-10-20)
Problem 1. Post-ESHAP renal dysfunction with electrolyte wasting risk
Problem 2. Chemotherapy-induced cytopenias with current neutrophil-predominant leukopenia and absolute lymphopenia
Problem 3. Mobilization and apheresis readiness for planned PBSC collection
Problem 4. Pulmonary function impairment with low diffusion capacity and small airway disease
Problem 5. Infectious risk profile and immunization gaps prior to transplant
Problem 6. Gastrointestinal toxicity prevention (nausea, mucositis, constipation) and ocular prophylaxis
Problem 7. Demographics discrepancy and nutrition/hydration status
Active inpatient medications of note (2025-10-20)
Follow-up checkpoints
Key Insights/Summary
Problem 1. Relapsed classical Hodgkin lymphoma (lymphocyte-rich), Lugano stage I, planned autologous PBSC collection
Problem 2. Chemotherapy-induced myelosuppression (neutropenia and anemia), current leukopenia
Problem 3. Cisplatin-related nephrotoxicity and electrolyte wasting risk
Problem 4. Infectious risk management and transplant-relevant serology/immunization
Problem 5. Cardiac and pulmonary baseline with prior anthracycline/bleomycin exposure
Problem 6. Chemotherapy-related nausea, GI dysmotility, and constipation
Problem 7. Vascular access and apheresis logistics
Problem 8. Incidental, longstanding imaging findings (lung nodule, hepatic hemangiomas, thyroid nodules)
Current Medications of note (hospital, 2025-10-14)
Safety labs and vitals snapshot
Notes
[exam finding]
2025-08-18 MRA - brain
2025-08-18 2D transthoracic echocardiography
[MedRec]
2025-10-28 ~ 2025-10-30 POMR Rheumatology and Immunology Chen ZhengHong
[immunochemotherapy]
[medication]
Benlysta (belimumab) 800mg IVD
Azaprine FC (azathoprine 50mg) 1# QOD
Compesolon (prednisolone 5mg)
Plaquenil (hydroxychloroquine 200mg)
2018-04-02 ~ ongoing 1# QOD~BID OPD
[differential diagnosis based on lab results only]
Summary ranking based on labs alone
Overview link between differentials and 2019 EULAR/ACR SLE criteria
Differential 1: SLE with immune thrombocytopenia–dominant phenotype
Differential 2: SLE with Evans syndrome
Differential 3: Primary immune thrombocytopenia (ITP) with background autoimmunity
Differential 4: Antiphospholipid-related thrombocytopenia / evolving APS overlap
Differential 5: Other ANA-positive CTD / UCTD
Practical integrated monitoring framework
Summary up front
Entry criterion
Clinical domains
Immunologic domains
Entry criterion
Domain scores (only highest per domain)
Total EULAR/ACR points
Classification threshold
Brain MRA 2025-08-18
Echocardiography 2025-08-18
Given:
I would not treat this as “borderline” any more:
Therefore, in a formal note I would phrase it as:
If you specifically want a “probability” language for research or teaching purposes:
Given this confirmed classification, I would frame ongoing monitoring around the SLE organ domains that are:
already involved, or
at high risk given the antibody/complement profile.
Hematologic
Immunologic activity markers
Renal
Musculoskeletal / quality of life
Neuropsychiatric
Cardiovascular / thrombotic risk
Key insights / summary (2025-12-05)
Problem 1. Systemic lupus erythematosus – overall disease activity and control
Problem 2. Immune thrombocytopenia and leukopenia (SLE-associated)
Problem 3. Antiphospholipid antibodies and thrombotic risk
Problem 4. Renal function and prevention of lupus nephritis
Problem 5. Infection risk under multi-agent immunosuppression
Problem 6. Neuropsychiatric and psychosocial issues
Problem 7. Long-term medication safety (steroids, azathioprine, hydroxychloroquine, biologics)
[exam finding]
2025-12-03 CXR
2025-12-03 2D transthoracic echocardiography
2025-11-24 MRI - lower abdomen
2025-10-29 ECG
2025-10-29 CXR
2025-10-11 CT - abdomen
2023-08-24 CXR
2023-08-14 MR Cholangiography, MRCP
2023-08-11 ECG
2023-08-09 ECG
2023-07-26 Sonography - abdomen
2023-07-10 CXR
2023-06-29 ECG
2023-06-25 ECG
2023-06-24 CT - abdomen
2023-06-24 ECG
2019-10-11 MRI - lower extremity
2019-09-27 Sonography - joint soft tissue
2019-07-11 Color Transcranial Doppler; carotid phenoangiograph, CPA
2019-07-05 2D transthoracic echocardiography
2019-07-02 MRA - brain
2019-06-30 CT - brain
2019-06-28 CT - brain
[MedRec]
2025-11-21 SOAP Hemato-Oncology Lin YiTing
2025-11-21 SOAP Urology Li MingWei
2025-10-29 ~ 2025-10-31 POMR Urology Li MingWei
2025-09-24, 2025-07-02 SOAP Rehabilitation Zhang YiWei
2023-06-24 ~ 2023-08-19 POMR
2013-10-16 ~ 2013-10-20 POMR Urology Zhang ShangRen
2012-10-23 ~ 2012-10-25 POMR Urology Zhang ShangRen
2006-11-23 ~ 2006-11-25 POMR Urology Cai YaoZhou
2005-10-26 ~ 2002-10-29 POMR
2005-08-28 ~ 2005-08-31 POMR Urology
[consultation]
2023-08-04 Rheumatology and Immunology
2023-06-28 Cardiology
[surgical operation]
2025-10-30
[chemotherapy]
[based on TEMP “gemcitabine + carboplatin” regimen]
Key insights / summary
Problem 1. Metastatic urothelial carcinoma of bladder and ureter with right inguinal and lung metastases (stage IV)
Problem 2. Chronic kidney disease with bilateral hydronephrosis and PCNs under nephrotoxic chemotherapy
Problem 3. Cardiovascular and cerebrovascular disease with arrhythmia and preserved LV function
Problem 4. Infection risk in an immunocompromised host with PCNs, port-A, and prior severe infections
Problem 5. Resolved hepatitis B infection and prior hepatitis of uncertain etiology under planned chemotherapy
Problem 6. Type 2 diabetes mellitus and metabolic control under chemotherapy and steroids
Problem 7. Sleep disturbance and chronic benzodiazepine use
Problem 8. Functional status, frailty, and rehabilitation needs
[lab data]
2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO
[exam finding]
2025-11-28, 2025-11-27 KUB
2025-11-18 CXR
2025-11-18 ECG
2025-10-31 Pap’s Smear
2025-10-29 Sonography - abdomen
2025-10-07 CT - abdomen
2025-09-20 Abdomen - Standing (Diaphragm):
2025-09-04 Nerve Conduction Velocity, NCV
2025-08-21 PET
2025-07-30 Colonoscopy
2025-07-25 Pathology - vaginal biopsy
2025-07-08 CT - abdomen
2025-04-08 CT - abdomen
2025-04-08 Colonoscopy
2025-01-15, 2024-11-06 CT - abdomen
2024-10-11 Pathology - bone biopsy/curretting
2024-10-01 PET
2024-08-30 MRI - pelvis (at TMUH)
2024-08-06 CT - abdomen
2024-06-04 MRI
2024-02-01 PET
2023-11-08 CT - abdomen
2023-07-04 CT - abdomen
[MedRec]
2025-11-19 ~ 2025-12-01 POMR Hemato-Oncology Xia HeXiong
2025-11-18 SOAP Hemato-Oncology Xia HeXiong
2025-11-11 SOAP Hemato-Oncology Xia HeXiong
2024-11-26 SOAP Hemato-Oncology Xia HeXiong
2025-10-21 SOAP Hemato-Oncology Xia HeXiong
2025-10-07 SOAP Neurology Chen PeiYa
2023-04-13 ~ 2023-04-21 POMR Hemato-Oncology Xia HeXiong
[radiotherapy]
[chemotherapy]
[Subjective]
Symptom control after discharge
Medication understanding and adherence
Perception of long-term complications - The patient is aware of bone involvement and understands that, given prior three radiotherapy courses, the physician may consider Xgeva (denosumab) in the future depending on the clinical situation.
[Objective]
Clinical status and recent hospitalization
Hepatitis B status and prophylaxis
Electrolytes, renal and hepatic function
Hematology
Neuropathy and bone involvement
Current discharge medications (2025-12-01)
[Assessment]
Medication-related symptom control after discharge
Baraclude (entecavir) prophylaxis and administration
Neuropathy monitoring and functional impact
Hypokalemia and electrolyte management
Bone metastases, prior RT, and potential Xgeva (denosumab)
Overall medication safety and optimization opportunities - Baraclude (entecavir) is appropriate but may require extension to continuous prophylaxis rather than short bursts. - MgO (magnesium oxide) and dietary counseling are appropriate for mild hypokalemia but may need adjunct oral potassium supplements if future labs remain low. - Mosapin (mosapride citrate) appears effective for GI symptoms, and no major safety concern is noted short term. - Alpraline (generic not specified) is prescribed PRN; no adverse effects have been reported; however, its necessity should be periodically reviewed to minimize polypharmacy. - There is no current signal of poor adherence; the patient is engaged and proactive about diet and medication use, making her a good candidate for shared decision-making in further therapy.
[Plan / Recommendation]
Symptom control and follow-up
Baraclude (entecavir) prophylaxis
Neuropathy
Electrolytes: potassium and magnesium
Bone metastases and potential Xgeva (denosumab)
General medication safety and coordination
Key insights / Summary
Problem oriented deliberation
Problem 1. Metastatic rectosigmoid colon adenocarcinoma with progressive liver and bone metastases under multi-line therapy
Problem 2. Suspected oxaliplatin-induced immediate hypersensitivity and recurrent infusion-related fever
Problem 3. Recent febrile episode with sepsis work-up and presumed urinary tract infection
Problem 4. Chemotherapy-related anemia and thrombocytopenia
Problem 5. Chronic hepatitis B (HBsAg negative, anti-HBc positive) under prophylaxis
Problem 6. Chemotherapy-induced peripheral and small fiber neuropathy
Problem 7. Electrolyte disturbances and metabolic profile (hypokalemia, low-normal magnesium, elevated LDH)
Problem 8. Bone metastases and skeletal complications
Problem 9. Cardiovascular risk and thrombosis potential
Problem 10. Symptom burden and insomnia
[Bedside visit for reported ADR: suspected oxaliplatin-induced fever]
Visited the patient in the ward at 11:15 with her husband present. Explained that her recent chemotherapy (Mvasi + FOLFOX) had been reported as an ADR case, and asked her to describe her symptoms.
The patient stated:
I provided feedback regarding the current urine culture:
Possibility of cytokine release syndrome (CRS):
Possibility of oxaliplatin-related hypersensitivity:
Assessment summary:
2025-11-18 來院接受化學治療, 輸注 Oxalip 167cc, Covorin 179cc 時發現有發熱。 因先前服用的退燒藥物,觀察30分鐘看體溫有無下降,後續體溫不降,故與家屬及病人討論完,先從病人中port-A抽血,用來評斷是否有port-A感染之可能,並轉介給急診後入院,在培養結果尚未出來時先投給 Brosym (11/19 ~ 11/25).
2025-11-21 上午 11:15 至病房訪視病人,請病人描述經過 病人表示換成 Mvasi + FOLFOX 後 迄今所打的四次之中 第一第二次發熱到約38度 第三次較不明顯到37度 第四次(2025-11-18施打)則有到39度,但是星期日(2025-11-16)就感覺自己略有發熱,病人這幾次有服用自家的普拿疼 病人回想 2023年四月初次使用 FOLFOX 時一開始似乎也有發熱的現象 (當時未並用 bevacizumab)
自解尿的結果是 50000 CFU/CC 單一菌種,無明顯尿路症狀,而成人,無導尿管情況下,一般判讀是難確認發熱是 UTI 所造成的。血液(含port-A)培養則無結果。
2025-11-25 rechallenge, 增加前藥 diphenhydramine 劑量為 50mg 並新增 famotidine 20mg + hydrocortisone 100mg + acetaminophen 500mg PO (通報本案時所用者為 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL) 輸注後發現皮膚四肢起紅斑, 病人感覺呼吸困難, 給予 dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + hydrocortisone 100mg + epinephine 0.3mg SC 後緩解。 2025-11-26 中午至病房訪視, 病人表示皮膚與呼吸喘等已消退。
[MedRec]
2025-12-02, 2025-09-09 SOAP Nephrology Wu ZheXiong
2025-11-18 ~ 2025-11-21 POMR Cardiology Zhou XingHui
2025-10-16 SOAP Cardiology Zhou XingHui
[Subjective]
Lower extremity pain and thrombosis concern
Medication understanding and cardiovascular–renal risk perception
[Objective]
Recent cardiovascular event and procedures
Renal function and diabetic nephropathy
Glycemic and lipid control
Inflammation and coagulation
[Assessment]
Lower extremity pain with concern for thrombosis
Post-NSTEMI state with DES implantation and need for guideline-concordant DAPT
Chronic kidney disease with diabetic nephropathy under partial control
Glycemic and lipid management
Medication regimen complexity and potential optimization opportunities
Patient education and understanding
[Plan / Recommendation]
Lower extremity pain and thrombosis concern
Post-NSTEMI and DAPT management
CKD and diabetic nephropathy optimization
Glycemic, lipid, and lifestyle management
Medication regimen simplification and safety
Ongoing patient education and follow-up
[exam finding]
2025-11-27 Tc-99m MDP bone scan
2025-10-28 2D transthoracic echocardiography
2025-10-09 Sonograph - neck (lymph node)
2025-09-02 Sonography - abdomen
2025-08-13 Sonography - gynecology
2025-07-11 2D transthoracic echocardiography
2025-05-15 Tc-99m MDP bone scan
2025-04-16 2D transthoracic echocardiography
2025-04-14 Bladder Sonography
2025-04-14 Uroflowmetry
2025-03-18 Sonography - abdomen
2025-03-07 CT - brain
2025-03-03 Sonography - gynecology
2025-01-17 2D transthoracic echocardiography
2024-12-26 Tc-99m MDP bone scan
[MedRec]
2025-11-25 ~ 2025-11-27 POMR General and Gastrointestinal Surgery Li ChaoShu
2025-10-28 ~ 2025-10-29 POMR General and Gastrointestinal Surgery Li ChaoShu
2022-06-19 ~ 2022-06-27 POMR Oral and Maxillofacial Surgery Xu BoZhi
2022-04-19 ~ 2022-04-20 POMR General and Gastrointestinal Surgery Li ChaoShu
[surgical operation]
2023-03-31
2022-06-20
2021-12-31
2017-05-18
[immunochemotherapy]
2025-11-25 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-10-28 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-09-30 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-09-02 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-08-06 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-07-11 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-06-11 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-05-14 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-04-15 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-03-18 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-02-19 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2025-01-16 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-12-25 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-11-27 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-10-29 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-10-01 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-09-05 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-08-07 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-07-10 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2024-05-31 - Herceptin (trastuzumab) 600mg SC 5min + Faslodex (fulvestrant) 500mg IM
2004-05-15 - _______________________________________ Faslodex (fulvestrant) 500mg IM
2024-04-23 - Herceptin (trastuzumab) 600mg SC 5min (C83)
2024-04-02 - Herceptin (trastuzumab) 600mg SC 5min (C82)
2024-03-15 - Herceptin (trastuzumab) 600mg SC 5min (C81)
2024-02-22 - Herceptin (trastuzumab) 600mg SC 5min (C80)
2024-01-31 - Herceptin (trastuzumab) 600mg SC 5min (C79)
2024-01-09 - Herceptin (trastuzumab) 600mg SC 5min (C78)
2023-12-19 - Herceptin (trastuzumab) 600mg SC 5min (C77)
2023-11-29 - Herceptin (trastuzumab) 600mg SC 5min (C76)
….-..-..
2020-02-04 - Herceptin (trastuzumab) 600mg SC 5min (C16)
….-..-..
[medication]
Navelbine (vinorelbine) 20mg 2# QW25
Femara (letrozole 2.5mg) 1# QD
Prolia (denosumab) 60mg SC Q6M
Nolvadex (tamoxifen 10mg) 1# QD
Xgeva (denosumab) 120mg SC Q1M
PG2 Lyo Injection (polysaccharides of Astragalus membranaceus) 500mg NS 500mL IVD 3hr
[Subjective]
Bone-modifying therapy and bone disease status
Anti-HER2 therapy and cardiac concern
Vinorelbine-related neuropathy
[Objective]
Oncologic and skeletal status
Bone-modifying therapy exposure and MRONJ history
Cardiac status under long-term trastuzumab
Vinorelbine exposure and neuropathy risk
Current key medications (partial list, focused on this note)
[Assessment]
Denosumab continuation in the setting of stable bone disease and prior MRONJ
Cardiac safety under long-term Herceptin (trastuzumab)
Possible vinorelbine-induced peripheral neuropathy
Medication safety and pharmaceutical care opportunities
[Plan / Recommendation]
Denosumab (Prolia) reassessment
Cardiac surveillance and patient education under Herceptin (trastuzumab)
Neuropathy monitoring and vinorelbine risk management
Oral health and MRONJ prevention (linked to denosumab and overall care)
Documentation and follow-up
Key insight / summary
Problem 1. Metastatic HER2-positive, hormone receptor positive right breast cancer with bone-dominant disease on long-term trastuzumab / endocrine / vinorelbine
Problem 2. Skeletal metastases and bone-modifying therapy in the context of prior medication-related osteonecrosis of the jaw
Problem 3. Medication-related osteonecrosis of the jaw and recurrent oral infections
Problem 4. Chronic cancer-related pain and fatigue under high-potency opioid and adjuvant analgesic regimen
Problem 5. Cardiovascular status and long-term trastuzumab cardiotoxicity surveillance in a patient with prior ICA stent
Problem 6. Lower urinary tract symptoms and voiding dysfunction managed with tamsulosin and mirabegron
Problem 7. Major depressive disorder and psycho-oncologic burden
Problem 8. Chemotherapy and endocrine therapy toxicity monitoring (hematologic, neuropathic, and metabolic)
[lab data]
2025-10-15 HBV-DNA-PCR Target Not Detected IU/mL
2025-09-26 HBsAg Nonreactive
2025-09-26 HBsAg (Value) 0.52 S/CO
2025-09-26 Anti-HBs 29.68 mIU/mL
2025-09-26 Anti-HCV Nonreactive
2025-09-26 Anti-HCV Value 0.20 S/CO
2025-09-26 Anti-HAV IgG Reactive
2025-09-26 Anti-HAV IgG Value 13.28 S/CO
2024-08-22 Measles Ab (IgG) Equivocal Index
2024-08-22 Measles Ab (IgG) Val 1.2 index
2024-08-22 VZV IgG Positive Index
2024-08-22 VZV-G Value 5.3 Index
2024-08-21 Rubella IgG Negative
2024-08-21 Rubella IgG(Value) <10 IU/mL
2024-08-21 Anti-HBs 48.27 mIU/mL
2024-08-21 HBsAg Nonreactive
2024-08-21 HBsAg (Value) 0.38 S/CO
2024-08-21 Anti-HCV Nonreactive
2024-08-21 Anti-HCV Value 0.20 S/CO
[exam finding]
2025-11-04 ECG
2025-11-04, 2025-10-14 CXR
2025-10-14 ECG
2025-10-09 CT - abdomen
2025-10-09 2D transthoracic echocardiography
2025-10-08 Pathology - prostate needle biopsy
2025-10-07 Pathology - bone marrow biopsy
2025-10-03 PET
2025-09-26 Pathology (colon polyp)
2025-09-26 Pathology (stomach biopsy)
2025-09-26 KUB
2025-09-26 ECG
2025-09-26 Esophagogastroduodenoscopy (EGD)
2025-09-26 Sonography - abdomen
2025-09-09 SRT & WDS
2025-06-26 Pure Tone Audiometry
2025-06-26 Tone-Evoked ABR
2025-06-10 ENT Hearing Test
2024-10-15 Exercise ECG
2024-09-18 CT
2024-09-18 ECG
[MedRec]
2025-11-12, 2025-08-20, 2025-05-28, 2025-03-05, 2024-12-11, 2024-09-18 SOAP Cardiology Zhang HengJia
2025-10-14 ~ 2025-10-18 POMR Hemato-Oncology Gao WeiYao
2025-10-06 ~ 2025-10-09 POMR Hemato-Oncology Gao WeiYao
[immunochemotherapy]
Key insights / summary
Problem 1. High-grade gastric large B-cell lymphoma with bone marrow involvement on C3 Pola-R-CHP
Problem 2. Tumor lysis risk and metabolic management across cycles
Problem 3. Cyclophosphamide-associated hematuria and urinary tract monitoring
Problem 4. Bone marrow function: anemia, prior thrombocytopenia, and neutrophil dynamics under chemotherapy and Fulphila
Problem 5. Chronic hepatitis B core antibody positive on rituximab and anthracycline therapy
Problem 6. Cardiovascular comorbidities and anthracycline exposure (WPW, hypertensive heart disease, aortic valve sclerosis)
Problem 7. Electrolyte balance, renal function, and prior hypocalcemia
Problem 8. Coagulation activation and venous thromboembolism (VTE) risk
Problem 9. Gastro-esophageal reflux disease, upper GI lesions, and chemo-supportive gastroprotection
Problem 10. Medication reconciliation and potential optimization
Overall, as of 2025-12-03, he is tolerating C3 Pola-R-CHP well, with biochemical signs of response, controlled TLS risk, resolved cyclophosphamide-associated hematuria, and stable organ function. Ongoing attention to infection prophylaxis, VTE risk, cardiac surveillance, HBV prophylaxis, and careful medication reconciliation will be key to safely completing the planned chemotherapy course.
Summary
Problem 1. High-grade B-cell lymphoma (stomach) with bone marrow involvement, s/p cycle 1 Pola-R-CHP
Problem 2. Tumor lysis risk and biochemical monitoring
Problem 3. Infusion reaction to rituximab (Rixathon), grade 1
Problem 4. Thrombocytopenia, mild
Problem 5. Hematuria (new), likely non-glomerular
Problem 6. Chronic hepatitis B core Ab positive under anti-CD20 therapy
Problem 7. Cardiovascular comorbidity: WPW, aortic valve sclerosis; anthracycline exposure
Problem 8. Electrolyte and mineral abnormalities (borderline hypokalemia, low-normal calcium)
Problem 9. Coagulation activation and VTE risk in malignancy
Problem 10. GERD and GI mucosal disease; supportive care on chemotherapy
Current medication highlights (hospital MAR style; brand in parentheses)
Follow-up and monitoring plan
Medication/treatment-related problems and recommendations
[exam finding]
2025-11-19 MRI - brain
2025-11-19 Sonography - chest
2025-11-17 2D transthoracic echocardiography
2025-11-17, 2025-10-22, 2025-10-15 CXR
2025-10-22, 2025-10-15 KUB
2025-10-03 MRI - L-spine
2025-10-02 Sonography - chest
2025-10-01 CXR
2025-10-01 ECG
2025-09-25 2D transthoracic echocardiography
2025-08-12 CT
2025-07-14 Tc-99m MDP bone scan
2025-05-13 CT
2025-05-05 Tc-99m MDP bone scan
2025-04-02 2D transthoracic echocardiography
2025-02-17 CT - chest
2025-01-02 Tc-99m MDP bone scan
2024-11-12 CT - chest
2024-10-28 Tc-99m MDP bone scan
2024-09-25 Portable 24hr ECG
2024-09-25 2D transthoracic echocardiography
2024-09-03, 2024-06-26 CXR
2024-06-12 MRI - L-spine
2024-06-07 2D transthoracic echocardiography
2024-06-05 Mammography
2024-06-05 MRI - larynx
2024-05-21 CT - chest
2024-05-16 Tc-99m MDP bone scan
2024-05-08 PET
2024-04-30 Pathology - breast biopsy (no need margin)
2024-04-30 Sonography - breast
[MedRec]
2025-11-12 SOAP Hemato-Oncology Xia HeXiong
2025-10-01 ~ 2025-10-09 POMR Hemato-Oncology Xia HeXiong
2025-09-29, 2025-06-27, 2025-03-28 SOAP Cardiology Xie JianAn
2025-01-10, 2024-10-18 SOAP Cardiology Xie JianAn
2024-06-11 ~ 2024-06-17 POMR Hemato-Oncology Xia HeXiong
[consultation]
2024-06-13 Oral and Maxillofacial Surgery
[surgical operation]
2024-06-03
[chemotherapy]
[Medication]
Granocyte (lenograstim) 250mcg SC
Xgeva (denosumab) 120mg SC
Baraclude (entecavir 0.5mg) 1# QDAC
Key insights / summary
Problem 1. Metastatic ER+/PR+, HER2-negative left breast cancer with chest wall, lung, bone, and pleural metastases under second-line EC chemotherapy
Problem 2. Chemotherapy-induced neutropenic fever (recent) and ongoing high myelosuppression risk
Problem 3. Recurrent right pleural effusion and dyspnea, likely malignant
Problem 4. Bone metastases and low back pain
Problem 5. Chronic anemia and overall hematologic status
Problem 6. Electrolyte and metabolic disturbances (hypokalemia, low albumin, calcium)
Problem 7. Cardiac function under anthracycline therapy with mild valvular disease and hypertension
Problem 8. Chronic hepatitis B with resolved infection under Baraclude (entecavir) prophylaxis
Problem 9. Symptom management: nausea, vomiting, epigastric discomfort, constipation, cough, and pain
Overall, the patient currently has radiologically stable but symptomatic metastatic ER+/PR+, HER2-negative breast cancer on second-line EC chemotherapy, complicated by neutropenic fever and malignant pleural effusion. Continued EC with strong myelosuppression prophylaxis is reasonable for short-term disease control, but early planning for transition to endocrine-based targeted therapy, optimization of pleural management, vigilant infection and electrolyte monitoring, and meticulous symptom control are crucial to maintain quality of life and safety.
[Potential Medication Issues]
Problem 1. Overall systemic anticancer strategy (heavy chemotherapy, no current endocrine/CDK4-6 therapy)
Note for Problem 1
From “today” (2025-12-02) onward, a guideline-aligned systemic strategy for this HR+/HER2-, HER2 1+, ER 90%, PR 70%, Ki-67 50% metastatic breast cancer should:
A stepwise plan.
Overall principles (based on current guidelines for HR+/HER2- MBC)
Step 0. Current status and prerequisites
Step 1. Stop further EC chemotherapy after C3
Step 2. First endocrine-based line “from now”: AI + CDK4/6 inhibitor
Step 3. If AI + CDK4/6 not feasible, consider alternative first endocrine line
Step 4. Second endocrine-based line when AI + CDK4/6 fails
Step 5. Later lines and when to reconsider chemotherapy
Step 6. Supportive and local therapies alongside systemic strategy
Step 7. Ongoing reassessment and goals-of-care discussions
In short, from today onward, the most guideline-consistent pivot is:
Her bone metastases do not limit endocrine therapy; in fact, bone-only or bone-predominant metastases are a classic scenario where endocrine ± CDK4/6 therapy is preferred over chemotherapy, as long as there is no frank visceral crisis or rapidly failing organ.
Step-by-step reasoning for this patient
Conclusion
Problem 2. High risk of recurrent neutropenic fever under EC chemotherapy
Problem 3. Anthracycline cardiotoxicity risk under EC
Problem 4. Denosumab (Xgeva) therapy and calcium/vitamin D / dental safety
Problem 5. Electrolyte management and diuretic/bronchodilator-related hypokalemia
Problem 6. Polypharmacy and overlapping analgesic/acetaminophen exposure
Problem 7. Gastrointestinal regimen: multiple antiemetics, prokinetics, laxatives, anti-diarrheals
Problem 8. Anti-infective treatments: cefepime dosing and duration; HBV prophylaxis
Problem 9. Pleural drainage management
Overall, the key medication/treatment-related concerns are: heavy reliance on sequential chemotherapy without yet using endocrine/CDK4-6 therapy; high risk of recurrent neutropenic fever and anthracycline cardiotoxicity; denosumab-associated hypocalcemia and dental risks; electrolyte disturbances under diuretics and β2-agonist; polypharmacy with overlapping analgesics and GI drugs; and the need for a clear long-term strategy for malignant pleural effusion management. Addressing these will improve safety, align care with guideline-based practice, and enhance quality of life.
[exam finding]
2025-10-03 ECG
2025-10-03 2D transthoracic echocardiography
2025-06-06 2D transthoracic echocardiography
2025-02-19 Pathology - breast simple/partial mastectomy
2025-02-19 Lymphoscintigraphy
2025-02-18 CT - chest
2025-02-03 Pathology - breast biopsy (no need margin)
2024-07-01 Sonography - gynecology
2024-04-16 Sonography - abdomen
2024-03-25 Sonography - gynecology
[MedRec]
2025-11-28 ~ 2025-11-29 POMR Hemato-Oncology Xia HeXiong
2025-06-05 ~ 2025-06-07 POMR Hemato-Oncology Xia HeXiong
2025-02-18 ~ 2025-02-21 POMR General and Gastroenterological Surgery Wu Chaoqun
[surgical operation]
2025-05-21
2025-02-19
2019-11-28
[chemotherapy]
[exam finding]
2025-09-26 CXR
2025-09-24 PET
2025-09-17 KUB
2025-09-16 Pathology - ovary (tumor)
2025-09-12 Pathology - stomach biopsy
2025-09-12 Esophagogastroduodenoscopy, EGD
2025-09-12 Colonoscopy
2025-09-04 CXR
2025-08-28 MRI - pelvis
2025-08-26 CXR
[MedRec]
2025-11-25 ~ 2025-12-01 POMR Hemato-Oncology Xia HeXiong
2025-09-11 ~ 2025-09-26 POMR Obstetrics and Gynecology Huang SiCheng
[surgical operation]
2025-09-26 10:02
2025-09-15 16:35
2025-09-15 16:10
2025-09-15 15:15
[chemotherapy]
[exam finding]
2025-11-05 Pure Tone Audiometry, PTA
2025-09-23 Portable 24hr ECG
2025-09-19 2D transthoracic echocardiography
2025-07-18 Pathology - uterus (with or without SO) neoplastic
2025-07-18 Frozen Section
2025-07-14 CT
2025-07-11 Sonography - gynecology
2025-07-09 CT - abdomen
2025-07-04 Sonography - abdomen
2025-03-28 Sonography - pancreas
2025-01-03 Sonography - abdomen
[MedRec]
2025-11-04 ~ 2025-11-08 POMR Hemato-Oncology Xia HeXiong
2025-07-17 ~ 2025-07-27 POMR Obstetrics and Gynecology Huang SiCheng
[surgical operation]
2025-07-25 11:05
2025-07-25 10:25
2025-07-18 08:50
[radiotherapy]
2025-08-20 ~ 2025-10-16 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT (ShuangHe Hospital).
[chemotherapy]
[exam finding]
2025-11-24 CT - CTA Chest
2025-11-24 Sonography - vein
2025-11-24 2D transthoracic echocardiography
2025-11-10 Sono-guided injection
2025-10-28 Sono-guided injection
2025-10-21 Sonography-guided injection
2025-09-08 Sono - neck (lymph node)
2025-09-08 Nasopharyngoscopy
2025-04-16 Sono-guided injection
2025-04-14 Colonoscopy
2025-04-14 Esophagogastroduodenoscopy, EGD
2025-04-08 Sono-guided injection
2025-04-02 Sono-guided injection
2025-04-01 Sonograpy - joint soft tissue
2025-04-01 Sonography - joint soft tissue
2025-03-28 MRI - T-spine
2025-02-25 MRI - L-spine
2025-02-25 Bone densitometry - hip
2024-08-21 Sono-guided injection
2024-08-20 RRIV (R-R interval variation) and SSR (sympathetic skin response)
2024-08-07 MRI - L-spine
2024-08-07 Sono-guided injection
2024-07-23 Nerve Conduction Velocity, NCV
2024-07-16 Tc-99m MDP three phase bone scan
2024-04-15 Colonoscopy
2024-03-29 MRA - brain
2024-02-20 CT - abdomen
[MedRec]
2025-10-18 ~ 2025-11-15 POMR Rheumatology and Immunology Chen ZhengHong
2025-03-30 ~ 2025-04-20 POMR Rheumatology and Immunology Chen ZhengHong
2024-08-04 ~ 2024-08-25 POMR Rheumatology and Immunology Chen ZhengHong
2024-04-14 ~ 2024-04-16 POMR Gastroenterology Xiao ZongXian
2024-01-14 ~ 2024-01-22 POMR Orthopedics Zhou BoZhi
2023-12-14 ~ 2023-12-20 POMR General and Gastrointestinal Surgery Chen YenZhi
2022-05-30 ~ 2022-07-01 POMR Hemato-Oncology Xia HeXiong
2022-04-08 ~ 2022-05-05 POMR Hemato-Oncology Xia HeXiong
2022-01-06 ~ 2022-01-15 POMR Orthopedics Zhou BoZhi
2020-07-07 ~ 2020-07-19 POMR Hemato-Oncology Zhang ShouYi
2019-04-21 ~ 2019-05-27 POMR Rheumatology and Immunology Chen ZhengHong
2019-01-17 ~ 2019-01-28 POMR Rheumatology and Immunology Chen ZhengHong
2018-11-26 ~ 2018-12-22
2018-09-06 ~ 2018-10-03
2018-07-10 ~ 2018-07-14
Key insights / summary (2025-11-27)
Problem 1. Dyspnea with left subclavian vein thrombosis, rule out pulmonary embolism / cardiopulmonary compromise
Problem 2. Catheter-related left subclavian vein thrombosis
Problem 3. Secondary adrenal insufficiency under current systemic steroid exposure
Problem 4. Chronic complex regional pain syndrome and neuropathic pain (bilateral lower limbs, knees, back, and upper limb involvement)
Problem 5. Structural spine disease and dorsal epidural T5–6 lesion (probable benign tumor) with chronic back pain
Problem 6. Iron deficiency (very low ferritin) without overt anemia
Problem 7. Osteopenia, chronic steroid exposure, and bone health
Problem 8. Gastroesophageal reflux disease, superficial gastritis, and chronic constipation / melanosis coli
Problem 9. Overall organ function and metabolic status
This is a 45-year-old woman with a complex pain syndrome characterized by chronic lower back and extremity pain, functional limitations, and multiple comorbid neuropathies. She has a diagnosis of Complex Regional Pain Syndrome (CRPS), supported by clinical presentation, response to nerve blocks, and small fiber involvement on QST. Her pain is likely multifactorial, with contributions from:
The recent recurrent pain flare (VAS 8) and hospital readmission on 2025-03-30 align with CRPS reactivation and chronic spine pathology. The patient’s current condition is stable but vulnerable, with pain moderately controlled on ongoing nerve blocks and steroid tapering.
Problem 1. Complex Regional Pain Syndrome (CRPS)
Problem 2. Lumbosacral Degenerative Disc Disease with Radiculopathy
Problem 3. Thoracic Epidural Lesion (T5–6)
Problem 4. Small Fiber Neuropathy
Problem 5. Secondary Adrenal Insufficiency (not posted)
[lab data]
2025-02-25 BCR/abl (BM) (qual) Undetectable
2025-02-24 FLT3/ITD mutation (BM) Undetectable
2025-02-24 JAK2 gene mutation (quan) 0.00 %
[exam finding]
[MedRec]
2025-11-24 SOAP Hemato-Oncology Yang MuJun
2025-08-27 ~ 2025-09-04 POMR Hemato-Oncology Yang MuJun
2023-11-26 ~ 2023-11-28 POMR Hemato-Oncology He JingLiang
[consultation]
2025-08-08 Oral and Maxillofacial Surgery
2024-11-26 Oral and Maxillofacial Surgery
2024-09-23 Hemato-Oncology
2024-07-09 Hemato-Oncology
2024-07-08 Plastic and Reconstructive Surgery
2024-06-17 Hemato-Oncology
[surgical operation]
2025-02-20
2024-08-14
2024-06-17
[chemotherapy]
Key insights / summary (2025-11-27)
Problem 1. High-risk RAEB-2 MDS under Vidaza with persistent blasts and heavy transfusion dependence
Problem 2. Grade 4 thrombocytopenia with extreme bleeding risk and chronic platelet transfusion dependence
Problem 3. Chronic severe anemia with red cell transfusion dependence
Problem 4. Severe transfusional iron overload under intensified chelation (Jadenu)
Problem 5. Infection risk under MDS, Vidaza, central line and current anti-infective prophylaxis
Problem 6. Pleural effusions and cardiopulmonary status under volume load and diastolic dysfunction
Problem 7. Chronic kidney disease stage 3 exposed to nephrotoxic agents (Jadenu, Vemlidy, diuretics)
Problem 8. Electrolyte and metabolic balance under polypharmacy and QT-prolonging medications
Problem 9. Chronic hepatitis B under Vemlidy prophylaxis in the context of immunosuppression
Problem 10. Symptom burden, quality of life, and polypharmacy in an older high-risk MDS patient
Overall, the current management (Vidaza, intensive transfusion support, chelation, infection and bleeding prophylaxis) is broadly appropriate, but the situation remains extremely fragile. Close monitoring, ongoing reassessment of goals of care, and meticulous supportive care remain the cornerstones of her management as of 2025-11-27.
Key Insight/Summary
Problem 1. Persistent Pancytopenia with RAEB-2 under Vidaza Treatment
Problem 2. Severe Thrombocytopenia (Grade 4)
Problem 3. Anemia (Transfusion-Dependent)
Problem 4. Transfusional Iron Overload
Problem 5. Renal Function and Electrolyte Balance
Problem 6. Pleural Effusion and Pulmonary Findings
Problem 7. Chronic Hepatitis B (on antiviral prophylaxis)
Problem 8. Gastrointestinal and Nutritional Tolerance
Problem 9. Infection Control and Antimicrobial Prophylaxis
Problem 10. Psychosocial and Functional Status
The patient is a 69-year-old female with RAEB-2 transformed from MDS, currently experiencing profound pancytopenia, persistent anemia, severe thrombocytopenia, and increased blast count (up to 7% on 2025-09-29). She has received repeated red cell and platelet transfusions. Lab data from 2025-09-30 confirm ongoing hematological dysfunction with HGB 6.8 g/dL and PLT 21×10^3/uL. Ferritin remains markedly elevated (>3300 ng/mL), suggesting iron overload. Renal function is mildly impaired (eGFR 71.45 mL/min/1.73m² on 2025-09-29) but stable, and liver enzymes are within normal limits. Electrolytes are stable, with borderline hypocalcemia. There is no evidence of active bleeding or infection, and the recent WBC count has improved to 4.76×10^3/uL (2025-09-30) with a myeloid left shift and blast presence.
Problem 1. Persistent Anemia
Problem 2. Severe Thrombocytopenia
Problem 3. Disease Progression: Blasts 7% and Transformation Risk
Problem 4. Hyperferritinemia and Iron Overload
Problem 5. Renal and Electrolyte Status
Problem 6. Glycemic and Nutritional Status
Problem 7. Coagulation Status
Key Insight / Summary
Problem 1. Refractory Anemia with Excess Blasts (RAEB-2) (not posted)
Problem 2. Severe Thrombocytopenia with Bleeding Risk
Problem 3. Transfusion-Dependent Anemia
Problem 4. Pleural Effusion and Volume Overload (not posted)
Problem 5. Iron Overload (not posted)
Problem 6. Renal Function and Electrolyte Status (not posted)
This 69-year-old woman with MDS RAEB-2 continues to show persistent pancytopenia and progressive increase in peripheral blasts (5.1% on 2025-07-02), despite ongoing Vidaza (azacitidine) therapy since 2023-12. She remains transfusion-dependent for both RBCs and platelets, with recurrent bleeding episodes including gum bleeding. Chronic thrombocytopenia (PLT 2–7 x10^3/uL), anemia (HGB 6.6–8.7 g/dL), and rising ferritin (>4000 ng/mL) reflect disease progression and transfusion-related iron overload. Renal function fluctuates around CKD stage 3, with eGFR declining from 84.01 (2025-06-09) to 52.34 (2025-07-02). Bilateral pleural effusions persist without respiratory compromise. Current ECOG PS is 2. Supportive care includes transfusions, chelation (Jadenu), and symptomatic agents. Prognosis remains guarded.
Problem 1. Refractory anemia with excess blasts (RAEB-2)
Problem 2. Chronic transfusion-dependent thrombocytopenia
Problem 3. Iron overload
Problem 4. Renal insufficiency (CKD stage 3)
Problem 5. Bilateral pleural effusion
Problem 6. Normocytic anemia (not posted)
Problem 1. Acute-on-chronic anemia
Problem 2. Thrombocytopenia with mucosal bleeding
Problem 3. Leukemic transformation of MDS (RAEB-2 with persistent blasts)
Problem 4. Pleural effusion and respiratory monitoring
Problem 5. Renal function and electrolyte balance
Problem 6. Transfusion-related iron overload
This 68-year-old woman with myelodysplastic syndrome with excess blasts-2 (MDS-EB2) has undergone leukemic transformation into acute myeloid leukemia (AML), confirmed by bone marrow (98% cellularity with 30% CD34+ and CD117+ blasts on 2025-02-18) and lymph node biopsy (2025-02-20). Despite ongoing Vidaza (azacitidine) chemotherapy, she continues to exhibit persistent anemia, severe thrombocytopenia, and fluctuating leukocytosis with circulating blasts (up to 7.0% on 2025-05-12). She is also transfusion-dependent and demonstrates signs of iron overload (ferritin >4000 ng/mL since 2025-03), along with recurrent pleural effusions and mild fluid overload likely related to treatment and/or disease. Her cardiac function remains preserved (LVEF 78% on TEE 2025-04-17), though she exhibits aortic stenosis. She is currently ECOG PS 1, afebrile, and stable on supportive care.
Problem 1. Acute Myeloid Leukemia (secondary to MDS-EB2)
Problem 2. Severe Thrombocytopenia
Problem 3. Transfusion-Dependent Anemia
Problem 4. Iron Overload
Problem 5. Electrolyte Abnormalities: Hypokalemia
Problem 6. Bilateral Pleural Effusions (AML-related) (below not posted)
Problem 7. Cardiovascular Status
Problem 1. AML Secondary to MDS with Persistent Cytopenia
Problem 2. Malignant Pleural Effusion
Problem 3. Persistent Hypokalemia
Problem 4. Hemodynamic and Vital Sign Stability
Problem 5. Severe Thrombocytopenia
Problem 6. Chronic Iron Overload
Patient Review
Problem 1. Acute Myelogenous Leukemia (AML) Transformation from MDS
Problem 2. Persistent Severe Cytopenia (Anemia & Thrombocytopenia)
Problem 3. Extensive Lymphadenopathy & Splenomegaly – Suspected Extramedullary AML vs. Lymphoma Transformation
Problem 4. Bilateral Pleural Effusions & Minimal Ascites – Suspected Malignant or Inflammatory Etiology
Problem 5. Splenic Lesions – Possible Myeloid Sarcoma vs. Infiltrative Disease
Conclusion & Next Steps (not posted)
[Treatment for AML-MDS and de novo AML] (not posted)
The treatment for acute myeloid leukemia (AML) arising from myelodysplastic syndromes (AML-MDS) and de novo AML should generally be different due to key biological, clinical, and prognostic differences between the two entities.
Reasons for Treatment Differences:
Conclusion:
[adapting Vidaza (azacitidine) dosing in MDS treatment]
The patient, weighing 59kg with a height of 159cm, has a BMI of 23.3 kg/m2 and a BSA of 1.61 m2.
For MDS, azacitidine administration is typically recommended as follows:
Alternative dosing schedules include:
For this patient, Vidaza (azacitidine) was administered at an approximate dosage of 62 mg/m2/day (100mg/day) for 3 or 2 days, with intervals varying from 1 to 3 weeks. This represents a lower dosage (mg/kg/day), shorter duration (reduced from the recommended 7 or 5 days to 3 or 2 days), and a more frequent dosing schedule (shorter cycle intervals). Deviating from the standard recommended regimen could potentially yield different therapeutic outcomes from the original regimen’s design.
[transfusion-dependent patient: elevated ferritin suggests iron overload, deferasirox considered]
Given the patient’s history of receiving multiple blood transfusions monthly for an extended period, lab data from 2023-12-13 revealed a serum ferritin level of 2261.8 ng/mL, suggesting the possibility of iron overload. Jadenu (deferasirox), the sole iron chelator available at this institution, could be considered as a treatment option. As of 2024-02-16, the patient’s ALT level was 14 U/L and the eGFR was 60.88 ml/min/1.73m^2, indicating no contraindications for using this medication. Jadenu treatment may be initiated at a dosage of 14 mg/kg daily, with subsequent dose adjustments every 3 to 6 months, depending on serum ferritin levels.
Jadenu (deferasirox) at a daily dose of 360 mg has been administered since Dec 2023. This dosage is below the suggested level of 14 mg/kg for a 59 kg individual, which would amount to 826 mg daily.
[exam findings]
2025-10-27 ECG
2025-10-07 Pathology - bone marrow biopsy
2025-10-06 CXR
2025-09-19 Pathology - kidney biopsy
2025-09-05 PET
2025-08-18 CT - abdomen
2025-05-06 MRI - pelvis
2025-03-05 CXR
2025-03-04 Pathology - colon segmental resection for tumor
2025-02-26 Sigmoidoscopy
2025-02-26 Flow volume chart
2025-02-25 ECG
2025-01-24 CT - abdomen
2024-12-20 Transesophageal echocardiography, TEE
2024-12-09 MRI - pelvis
2024-11-06 Transesophageal echocardiography, TEE
2024-08-13 2D transthoracic echocardiography
2024-08-12 ECG
2024-08-10 CT - abdomen
2024-06-18 Colonoscopy
2024-05-14 Sigmoidoscopy
2024-05-13 MRI - pelvis
2024-02-27 2D transthoracic echocardiography
2024-02-16 PET
2024-02-15 ECG
2024-02-15 CXR
2024-02-08 RAS & BRAF V600 MassArray
2024-01-24 Pathology - colon biopsy
2024-01-11 MRI - pelvis
2024-01-10 CT - abdomen
2023-12-22 Pathology
[MedRec]
2025-10-27 ~ 2025-10-31 POMR Hemato-Oncology Yang MuJun
2025-03-03 ~ 2025-03-14 POMR Colorectal Surgery Lv ZongRu
2025-02-25 ~ 2025-02-26 POMR Colorectal Surgery Lv ZongRu
2024-03-29 ~ 2024-04-01 POMR Integrative Medicine Yang MuJun
[consultation]
2024-08-12 Cardiology
2024-04-15 Rehabiliation
[surgical operation]
2025-05-20
2025-03-04
2024-02-07
[radiotherapy]
[chemotherapy]
Key insights / summary up to 2025-11-27
Problem 1. Left perirenal diffuse large B-cell lymphoma, Lugano stage IV, IPI 4
Problem 2. Chemotherapy-related cytopenias and infection prophylaxis
Problem 3. Renal function impairment and hyperuricemia / tumor lysis risk
Problem 4. Chronic viral hepatitis B under rituximab-based chemotherapy
Problem 5. History of rectal adenocarcinoma, post total neoadjuvant therapy and low anterior resection
Problem 6. History of hepatocellular carcinoma s/p radiofrequency ablation
Problem 7. Hypertension and cardiovascular risk
Problem 8. Insomnia, psychosocial status, and quality of life
Problem 9. Gastrointestinal function and supportive medications
Overall, the patient currently tolerates C3 R-COP reasonably well with stable performance status, moderate but manageable cytopenias, and preserved organ function. The most critical issues to address promptly are optimization of HBV prophylaxis, careful management of renal function and infection prophylaxis, and structured response assessment for DLBCL, all while continuing long-term surveillance for prior rectal cancer and HCC and maintaining quality of life.
[frequently neutropenia despite reduced oxaliplatin dosage]
Granocyte (lenograstim 250ug) was administered on 2024-08-26, and currently, there is no evidence of neutropenia.
This patient appears to have a tendency towards neutropenia with the FOLFOX regimen. Despite oxaliplatin being used at only half the standard dose initially, and further reduced to 40% since late June, neutropenia continues to be frequently observed.
2024-08-27 WBC 6.54 x10^3/uL
2024-08-26 WBC 1.86 x10^3/uL
2024-08-27 Neutrophil 87.3 %
2024-08-26 Neutrophil 78.3 %
[febuxostat treatment for hyperuricemia]
The patient’s elevated serum uric acid levels are being managed with Feburic (febuxostat). The treatment is well-tolerated, and no issues or adverse effects have been identified.
[WBC count returns to normal after neutropenia]
Neutropenia has resolved, and the WBC count is now within the normal range.
2024-08-10 WBC 6.69 x10^3/uL
2024-08-09 WBC 1.59 x10^3/uL
2024-08-10 Neutrophil 90.6 %
2024-08-09 Neutrophil 64.8 %
[potential impact of earlier radiotherapy on pancytopenia; assessing patient tolerance to transfusion and G-CSF]
Lab data showed persistent pancytopenia, with fluctuations in severity but almost never returning to normal levels. Even on the day of receiving CCRT on 2024-02-08, the values were below normal, suggesting that earlier radiotherapy (from 2024-02-01) may also be a contributing factor. The patient began neoadjuvant FOLFOX treatment on 2024-03-30 (with all three sessions at a reduced dose), and pancytopenia has worsened since then.
If the patient tolerates LPRBC or LRP transfusion and G-CSF administration, the reduced dose regimen might be continued. However, if the patient cannot tolerate it and there is no substantial improvement in pancytopenia, alternative regimens or treatment approaches may need to be considered.
2024-06-03 WBC 2.33 x10^3/uL Neutrophil 83.2 %
2024-05-31 WBC 1.43 x10^3/uL Neutrophil 81.0 %
2024-05-27 WBC 1.80 x10^3/uL Neutrophil 68.4 %
2024-05-09 WBC 2.29 x10^3/uL Neutrophil 75.5 %
2024-04-15 WBC 2.35 x10^3/uL
2024-04-08 WBC 1.86 x10^3/uL
2024-03-29 WBC 2.64 x10^3/uL
2024-03-25 WBC 2.12 x10^3/uL
2024-03-18 WBC 2.32 x10^3/uL
2024-02-20 WBC 3.94 x10^3/uL
2024-02-15 WBC 2.81 x10^3/uL
2024-02-08 WBC 2.77 x10^3/uL
2024-06-03 HGB 13.9 g/dL
2024-05-31 HGB 7.1 g/dL
2024-05-27 HGB 11.2 g/dL
2024-05-09 HGB 9.9 g/dL
2024-04-15 HGB 9.7 g/dL
2024-04-08 HGB 10.7 g/dL
2024-03-29 HGB 10.0 g/dL
2024-03-25 HGB 11.0 g/dL
2024-03-18 HGB 11.4 g/dL
2024-02-20 HGB 11.5 g/dL
2024-02-15 HGB 11.4 g/dL
2024-02-08 HGB 11.9 g/dL
2024-06-03 PLT 61 *10^3/uL
2024-05-31 PLT 44 *10^3/uL
2024-05-27 PLT 62 *10^3/uL
2024-05-09 PLT 59 *10^3/uL
2024-04-15 PLT 68 *10^3/uL
2024-04-08 PLT 75 *10^3/uL
2024-03-29 PLT 65 *10^3/uL
2024-03-25 PLT 59 *10^3/uL
2024-03-18 PLT 56 *10^3/uL
2024-02-20 PLT 86 *10^3/uL
2024-02-15 PLT 79 *10^3/uL
2024-02-08 PLT 85 *10^3/uL
[exam finding]
2025-11-27 CXR
2025-11-27 Eye Photography
2025-11-27 MicroSonography
2025-10-24 MRI - knee
2025-09-22 MRI - brain
2025-09-22 CXR
2025-09-22 Microsonography
2025-09-19 Mammography
2025-08-24 CXR
2025-08-20 Sonography - gynecology
2025-07-29 Lung Function Test
2025-07-29 2D transthoracic echocardiography
2025-07-28 CXR
2025-07-04 MRI - brain
2025-07-03, 2025-06-13 CXR
2025-05-23 CXR
2025-05-16 Sonography - nephrology
2025-05-13 Pathology - bone marrow biopsy
2025-05-09 MRI - T-spine
2025-05-08 PET
2025-05-06 CT - brain
2025-05-03 CT - abdomen
2025-04-29 Pathology - brain biopsy
2025-04-28 17:33 CT - brain
2025-04-28 16:25 MRA - brain
2025-04-28 KUB
2025-04-28 13:09 CT - brain
2025-04-28 ECG
[MedRec]
2025-09-25 ~ 2025-09-30 POMR Hemato-Oncology Yang MuJun
[consultation]
2025-11-27 Ophthalmology
2025-08-27 Obstetrics and Gynecology
2025-05-15 Nephrology
2025-05-08 Ophthalmology
2025-05-07 Hemato-Oncology
2025-04-29 Anesthesia
2025-04-28 Neurosurgery
2025-09-22 MRI - brain
2025-09-22 CXR
2025-09-22 Microsonography
2025-09-19 Mammography
2025-08-24 CXR
2025-08-20 Sonography - gynecology
2025-07-29 Lung Function Test
2025-07-29 2D transthoracic echocardiography
2025-07-28 CXR
2025-07-04 MRI - brain
2025-07-03, 2025-06-13 CXR
2025-05-23 CXR
2025-05-16 Sonography - nephrology
2025-05-13 Pathology - bone marrow biopsy
2025-05-09 MRI - T-spine
2025-05-08 PET
2025-05-06 CT - brain
2025-05-03 CT - abdomen
2025-04-29 Pathology - brain biopsy
2025-04-28 17:33 CT - brain
2025-04-28 16:25 MRA - brain
2025-04-28 KUB
2025-04-28 13:09 CT - brain
2025-04-28 ECG
[surgical operation]
2025-05-12
2025-04-29
[chemotherapy]
2025-11-27 - etoposide 2.5mg/kg 200mg NS 500mL Q6H 4hr D1-4 (16 doses) + cytarabine 2000mg/m2 2500mg NS 500mL Q12H D1-3 (6 doses) (EA consolidation)
2025-09-30 - Tamos (temozolomide 100mg) 2# QDAC D1-4
2025-09-26 - methotrexate 4000mg/m2 7500mg NS 500mL 12hr
2025-08-28 - Tamos (temozolomide 100mg) 2# QDAC D1-4
2025-08-25 - methotrexate 4000mg/m2 7500mg NS 500mL 12hr
2025-08-04 - Tamos (temozolomide 100mg) 2# QDAC D1-4
2025-07-29 - methotrexate 4000mg/m2 7500mg NS 500mL 12hr
2025-08-02 - Tamos (temozolomide 100mg) 2# QDAC D1-7
2025-07-04 - methotrexate 4000mg/m2 7600mg NS 500mL 12hr
2025-06-30 - rituximab 375mg/m2 680mg NS 500mL 4hr
2025-06-23 - rituximab 375mg/m2 680mg NS 500mL 4hr
2025-06-19 - Tamos (temozolomide 100mg) 2# QDAC D1-4
2025-06-16 - rituximab 375mg/m2 700mg NS 500mL 4hr
2025-06-13 - methotrexate 4000mg/m2 7500mg NS 500mL 12hr
2025-06-06 - rituximab 375mg/m2 680mg NS 500mL 4hr
2025-05-29 - rituximab 375mg/m2 680mg NS 500mL 4hr
2025-05-16 - rituximab 375mg/m2 690mg NS 500mL 4hr
2025-05-14 - methotrexate 8000mg/m2 11700mg NS 500mL 12hr (80% dose for first C/T)
[note]
Methotrexate-based remission induction regimens for primary central nervous system lymphoma - 2025-08-25 - https://www.uptodate.com/contents/image?imageKey=NEURO%2F128319
Key insights / summary
Problem 1. Primary CNS diffuse large B-cell lymphoma – disease status and current EA consolidation
Problem 2. Anticipated myelosuppression and infection risk under EA
Problem 3. Neurologic deficit – left foot numbness and toe weakness
Problem 4. Renal function and metabolic safety under intensive chemotherapy
Problem 5. Electrolyte balance – recurrent mild hypokalemia and calcium/magnesium status
Problem 6. Hypertension and cardiovascular risk
Problem 7. Ophthalmologic issues – glaucoma, ERM, and cytarabine-related conjunctivitis risk
Problem 8. Musculoskeletal issues – right knee PCL/meniscal tear and functional status
Problem 9. Constipation, gastrointestinal protection, and nutrition
Problem 10. Psychosocial and global functional considerations
Overall, the patient is entering a critical phase of second-line/consolidation therapy with EA after successful but intensive MTR treatment. She currently has adequate organ function and hematologic reserve, but close monitoring of neurologic status, infection risk, renal function, electrolytes, and blood pressure is essential to safely deliver potentially curative therapy while maintaining quality of life.
[Potential Medication Issues]
Problem 1. Intensive EA regimen (etoposide + high-dose cytarabine) – myelosuppression and infection risk
Problem 2. Use of high-dose cytarabine with ocular toxicity and pre-existing glaucoma
Problem 3. Infection prophylaxis regimen vs overlapping hematologic toxicity
Problem 4. Antihypertensive regimen under steroids and intensive chemotherapy
Problem 5. Recurrent mild hypokalemia under chemotherapy and antihypertensives
Problem 6. Renal function and nephrotoxic exposures during and after EA
Problem 7. Use of systemic corticosteroids (dexamethasone) with glaucoma, hypertension, and hyperglycemia
Problem 8. Pain control and NSAID avoidance in the context of renal and platelet risks
Problem 9. Gastrointestinal protection, constipation management, and nutrition during EA
Problem 10. Growth factor support timing and dosing
She is a 60-year-old woman with biopsy-proven primary CNS DLBCL (non-GCB, stage IE) receiving MTR. Disease control is favorable: brain MRI shows no enhancing disease (MRI 2025-09-22). She is admitted for C6 high-dose methotrexate (HD-MTX 4,000 mg/m²; total 7,500 mg over 12 h) with standard rescue and alkalinized hydration (Chemo 2025-09-26; MAR 2025-09-25/09-27). Kidney function is currently preserved (Cr 0.86 mg/dL, eGFR 71.54 mL/min/1.73 m²; Chem 2025-09-25). UA shows low-grade pyuria/bacteriuria without fever (UA 2025-09-25). BP improved on dual therapy (VS 2025-09-26; MAR 2025-09-25).
Problem 1. Primary CNS DLBCL — response status and on-treatment management
Problem 2. HD-Methotrexate pharmacokinetics, nephroprotection, and rescue
Problem 3. Infection risk and possible lower UTI while on prophylaxis
Problem 4. Blood pressure and cardiovascular status
Problem 5. Hematologic status — mild anemia; myelosuppression surveillance
Problem 6. Renal function, electrolytes, and acid-base balance
Problem 7. Seizure risk and CNS supportive care
Problem 8. Gastrointestinal protection and bowel regimen
Problem 9. Vascular access and thrombosis/infection surveillance
Active inpatient medications of relevance today
Disposition/plan today (2025-09-26)
[GPT4o]
The patient is a 60-year-old woman with “primary CNS diffuse large B-cell lymphoma (non-GCB, stage IE)” confirmed by biopsy (2025-04-29), presenting initially with left-sided hemiparesis. She has completed multiple cycles of the MTR regimen (methotrexate, temozolomide, rituximab) with careful monitoring and rescue for methotrexate-induced renal toxicity. Latest MRI (2025-09-22) shows no active CNS lesions. She is currently admitted for C6 methotrexate (2025-09-26). Labs on 2025-09-25 reveal normalized renal function, mild anemia, and no significant cytopenia. She is off temozolomide this cycle due to prior GI intolerance.
Problem 1. Primary CNS DLBCL – Disease Status and Treatment Continuation
Problem 2. Methotrexate-Related Renal Risk and Rescue Strategy
Problem 3. Hematologic Profile – Mild Anemia and Myelosuppression Monitoring
Problem 4. Electrolyte and Acid-Base Balance – Mild MTX-associated Disturbances
Problem 5. Infection Prophylaxis and Urinary Tract Monitoring
Problem 6. Blood Pressure Management
The patient is a 60-year-old female diagnosed with primary CNS diffuse large B-cell lymphoma (DLBCL), non-GCB, stage IE, confirmed by biopsy on 2025-04-29. She is undergoing multi-cycle MTR (Methotrexate, Temozolomide, Rituximab) chemotherapy with supportive care. As of 2025-08-25, she has completed five doses of high-dose methotrexate (HD-MTX), multiple cycles of rituximab, and at least three courses of temozolomide. A brain MRI on 2025-07-04 showed only a tiny residual lesion, indicating partial remission. Clinical course was complicated by transient AKI in June, mild anemia, and electrolyte disturbances (hypokalemia, hypomagnesemia, hypocalcemia), which have been largely corrected. Vital signs are stable. Leucovorin rescue and hydration have been appropriately administered. The current status is stable with controlled tumor burden and preserved organ function.
Problem 1. Primary CNS diffuse large B-cell lymphoma (DLBCL)
Problem 2. Renal function and methotrexate clearance
Problem 3. Electrolyte imbalance
Problem 4. Anemia
Problem 5. Blood pressure control
This is a 60-year-old woman with primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL), stage IE, confirmed by brain biopsy on 2025-04-29. She is currently undergoing MTR chemotherapy regimen (Methotrexate, Temozolomide, Rituximab). The patient was readmitted on 2025-07-03 for Cycle 2, Day 1 high-dose methotrexate (HD-MTX) therapy. Laboratory monitoring and medication charts confirm the use of leucovorin (Covorin) as rescue therapy, consistent with high-dose MTX protocol. Renal function is stable (eGFR 54.42 on 2025-07-03), and vital signs are within acceptable ranges post-chemotherapy. No acute complications such as MTX-induced renal or hepatic toxicity are observed.
Problem 1. High-dose methotrexate-related toxicity prevention
Problem 2. Renal function under chemotherapy
Problem 3. Hematologic monitoring during MTR (not posted)
This is a 60-year-old woman with primary CNS diffuse large B-cell lymphoma (DLBCL, non-GCB, stage IE) confirmed by brain biopsy on 2025-04-29, currently undergoing induction chemotherapy with the MTR regimen (Methotrexate, Temozolomide, Rituximab). Her treatment has been complicated by prior acute kidney injury (AKI) after high-dose methotrexate on 2025-05-14, prompting a dose reduction in subsequent cycles. She was readmitted on 2025-06-12 for Cycle 1 Day 15 methotrexate infusion. As of 2025-06-13, she remains hemodynamically stable (BP range 141–170 mmHg), afebrile, fully conscious (E4V5M6), and tolerating the chemotherapy. Renal function has improved (eGFR 47.79 mL/min/1.73m²), urine output remains adequate, and methotrexate rescue (Covorin and hydration) is ongoing. No signs of sepsis, tumor lysis, or active infection are currently present.
Problem 1. Primary CNS DLBCL (Stage IE), s/p biopsy, on MTR regimen
Objective
Assessment
Recommendation
Problem 2. Renal function impairment (post-MTX AKI, now recovering)
Problem 3. Normocytic anemia (not posted)
Problem 4. Hypertension (essential, uncontrolled in past) (not posted)
[PCNS-DLBCL] (not posted)
There are clear diagnostic criteria met in the provided data to support the diagnosis of primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL) :
Supporting Evidence:
Diagnostic Definition (per WHO 5th ed. and NCCN 2025)
A diagnosis of Primary CNS Lymphoma (PCNSL) requires:
→ The patient meets all of the above criteria, so the diagnosis of Primary CNS DLBCL, stage IE is fully supported.
[leucovorin (folinic acid) is being used to mitigate methotrexate (MTX) toxicity] (not posted)
Leucovorin (folinic acid) is clearly being used to mitigate methotrexate (MTX) toxicity in this patient, and this is fully aligned with standard oncologic protocols.
Evidence from the simulated case:
Conclusion:
[exam finding]
2025-11-25 MRI - L-spine
2025-11-25 KUB + L-spine Lat
2025-11-25 CXR
2025-11-25 ECG
2025-10-23 Tc-99m MDP bone scan
2025-10-21 CXR
2025-10-21 ECG
2025-09-22 CXR
2025-09-22 ECG
2025-09-08 CXR
2025-09-02 RAS & BRAF V600 MassArray
2025-08-29 CT - abdomen
2025-08-29 CXR
2025-08-29 Colonoscopy
2025-08-18 Pathology
2025-08-12 Anoscopy
[MedRec]
2025-10-21 ~ 2025-10-24 POMR Hemato-Oncology He JingLiang
2025-10-03 MultiTeam - Psycho-oncology
2025-09-24 ~ 2025-10-03 POMR Hemato-Oncology He JingLiang
[consultation]
[surgical operation]
2025-09-08
[immunochemotherapy]
Key insights / summary
Problem 1. Metastatic rectal adenocarcinoma (stage IVB, KRAS p.G12D) on FOLFIRI ± bevacizumab
Problem 2. Multiple spinal metastases with right leg pain and risk of spinal cord complications
Problem 3. Dyspnea with pneumonia and possible heart failure
Problem 4. Atrial fibrillation with rapid ventricular response and high thromboembolic risk
Problem 5. Chronic kidney disease stage 3b with recurrent AKI and hyperkalemia
Problem 6. Hematologic status: prior chemotherapy-related cytopenias and current reactive thrombocytosis
Problem 7. Electrolyte and metabolic abnormalities (hyperkalemia, hyperuricemia, metabolic acidosis, calcium balance under denosumab)
Problem 8. Hepatitis B virus infection under prophylaxis
Problem 9. Symptom burden, nutrition, and psychosocial issues
[exam finding]
[MedRec]
2025-10-16 ~ 2025-10-21 POMR Hemato-Oncology Xia HeXiong
2025-09-25 SOAP Metabolism and Endocrinology Liao YuHuang
2025-05-08 SOAP Metabolism and Endocrinology Liao YuHuang
2025-03-20 SAOP Metabolism and Endocrinology Liao YuHuang
2022-09-07 ~ 2022-09-09 POMR Colorectal Surgery Xiao GuangHong
[surgical operation]
[chemotherapy]
2025-11-25 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 50mg/m2 50mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 100mL 10min + fluorouracil 1600mg/m2 2000mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-10-16 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 50mg/m2 50mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 100mL 10min + fluorouracil 1600mg/m2 2000mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-09-10 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-07-21 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-06-23 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-05-19 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 500mL 1hr IP (left in the abdomen for 24 hours, then drained using a vacuum bottle) + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-04-14 - [oxaliplatin 300mg/m2 408mg + mitomycin-C 18mg/m2 25mg] IP 90min
2025-02-19 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-01-07 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (cetuximab + FOLFOX)
2024-12-04 - cetuximab + FOLFOX
2024-11-15 - cetuximab + FOLFOX
2024-10-24 - cetuximab + FOLFOX
2024-10-01 - cetuximab + FOLFOX
2024-09-12 - cetuximab + FOLFOX
2023-11-23 - cetuximab + FOLFOX
2023-11-01 - cetuximab + FOLFOX
2023-10-05 - cetuximab + FOLFOX
2023-09-21 - cetuximab + FOLFOX
2023-05-08 - cetuximab + FOLFOX
2023-04-18 - cetuximab + FOLFOX
2023-03-31 - cetuximab + FOLFOX
2023-03-17 - cetuximab + FOLFOX
2023-03-03 - cetuximab + FOLFOX
2023-02-17 - cetuximab + FOLFOX
2023-01-30 - cetuximab + FOLFIRI
2022-12-29 - cetuximab + FOLFIRI
2022-12-14 - cetuximab + FOLFIRI
2022-11-29 - cetuximab + FOLFIRI
2022-11-10 - FOLFIRI
2022-10-24 - FOLFIRI
2022-10-06 - FOLFIRI
2022-09-21 - FOLFIRI
Key insights / summary
Problem 1. Metastatic descending colon adenocarcinoma on Erbitux (cetuximab) plus FOLFOX, post cytoreductive surgery and HIPEC
Problem 2. Chemotherapy and targeted therapy tolerance, including oxaliplatin allergy and cumulative toxicity
Problem 3. Liver function and chronic viral hepatitis B under Baraclude (entecavir)
Problem 4. Hematologic status: mild normocytic anemia and intermittent leukocytosis
Problem 5. Type 2 diabetes mellitus with steroid-related hyperglycemia
Problem 6. Nutritional status and cancer-related cachexia
Problem 7. Electrolyte balance and renal function
Overall, on 2025-11-26, the patient is clinically stable with good organ reserve and manageable treatment toxicity while receiving Erbitux (cetuximab) plus FOLFOX. The main emerging concern is rising CEA suggesting possible biochemical progression, which warrants structured restaging and strategic planning for subsequent lines of therapy while continuing meticulous supportive care.
She has metastatic descending colon adenocarcinoma (RAS/BRAF wild type) with prior multivisceral resection and CRS/HIPEC (2025-04-14), now on Cetuximab + FOLFOX with careful oxaliplatin desensitization. Restaging shows a small residual hepatic lesion at S8 (1.5 cm) without peritoneal disease (CT 2025-07-11). Tumor markers fell after surgery/chemo (CEA 62.16→2.16 ng/mL, 2025-04-07→2025-05-05) and remain low–normal with minor fluctuation (CEA 3.69 ng/mL, 2025-07-29). Organ function is adequate for ongoing therapy (CMP/CBC 2025-09-10). Current toxicities are mild (G1 neuropathy/fatigue; toxicity grid 2025-09-10). BMI remains ~17, so nutrition support is important. DM2 is generally controlled by A1c but with peri-chemo hyperglycemia (glucose 202 mg/dL, 2025-09-11) requiring adjustment while on steroids.
———
Problem 1. Metastatic descending colon adenocarcinoma, RAS/BRAF wild type, s/p CRS/HIPEC, on Cetuximab + FOLFOX
Problem 2. Oxaliplatin hypersensitivity and neurotoxicity (current G1 paresthesia)
Problem 3. Diabetes mellitus type 2 with peri-chemo hyperglycemia on steroids
Problem 4. Nutrition and cachexia (BMI ~17)
Problem 5. Viral hepatitis on nucleoside therapy (chart lists hepatitis C, medication indicates hepatitis B)
Problem 6. Hematologic tolerance to therapy with prior thrombocytopenia (resolved)
Problem 7. Organ function and electrolytes (fit for chemotherapy)
Problem 8. Prior right pleural effusion (resolved)
———
The patient is undergoing combination chemotherapy with cetuximab + FOLFOX for liver-metastasized malignancy, with evidence of a persistent 1.5 cm hepatic lesion in segment 8 (CT 2025-07-11). Recent labs (2025-07-21) indicate stable organ function, preserved marrow reserve, and normoglycemia (HbA1c 5.9% on 2025-07-01). No emergent complications are detected. Slight anemia (Hb 12.2 g/dL) and borderline platelet levels (PLT 156 ×10³/μL) are present but not worsening. Tumor markers (CEA, CA199) remain stable. There is no evidence of fluid retention, obstruction, or additional metastases. The disease status appears radiologically stable under ongoing systemic therapy.
Problem 1. Liver metastasis (segment 8)
Problem 2. Chemotherapy administration and tolerability (cetuximab + FOLFOX) (below not posted)
Problem 3. Mild normocytic anemia
Problem 4. Borderline thrombocytopenia
Problem 5. Glucose and metabolic profile
This 61-year-old woman with stage IVB descending colon adenocarcinoma (ypT4aN1aM1b), post extensive cytoreductive surgery and intraperitoneal chemotherapy (HIPEC on 2025-04-14), is currently receiving systemic FOLFOX plus Cetuximab therapy combined with 5-FU intraperitoneal infusion. Despite history of severe oxaliplatin hypersensitivity, infusion was resumed using prolonged administration and premedication without immediate allergic reaction. She presents with stable vital signs, tolerable clinical status (ECOG 1), borderline anemia, improving thrombocytopenia, and mild hyponatremia. The glucose profile shows mild fasting hyperglycemia likely related to steroid use. LFTs, renal function, and inflammatory markers have normalized post-op (compared to 2025-04-14 to 2025-04-17 hepatitis pattern and elevated CRP).
Problem 1. Metastatic descending colon adenocarcinoma, ypT4aN1aM1b, status post CRS + HIPEC
Problem 2. Chemotherapy-related hematologic suppression (anemia, thrombocytopenia)
Problem 3. Chemotherapy-related liver enzyme fluctuation and hepatotoxicity surveillance
Problem 4. Type 2 diabetes mellitus - mild steroid-related hyperglycemia (not posted)
Problem 5. Mild hyponatremia (not posted)
[exam finding]
2025-11-04 Lung Function Test
2025-10-30 Pathology - bone marrow biopsy
2025-10-30 Bronchodilator Test, BDT
2025-10-30 2D transthoracic echocardiography
2025-10-29 CXR
2025-10-29 ECG
[MedRec]
2025-11-20 SOAP Medical Emergency He YaoCan
2025-10-30 ~ 2025-11-19 POMR Hemato-Oncology Liu YiSheng
2025-10-30 SOAP Hemato-Oncology Liu YiSheng
2025-10-29 SOAP Hemato-Oncology He JingLiang
[consultation]
2025-10-31 Psychosomatic Medicine
[chemotherapy]
[medication]
Vemlidy (tenofovir alafenamide 25mg) 1# QD
Venclexta (venetoclax 100mg) 2# QDCC
Rydapt (midostaurin 25mg) 1# BID
2025-11-26
[Subjective]
Contact with caregiver
Previous subjective data from records
[Objective]
Hematologic/oncologic status
Pancytopenia and trend
Hematuria episode (2025-11-20)
Infection and organ function
Cardiopulmonary evaluation
Current and recent medications (discharge 2025-11-19 and ED 2025-11-20)
[Assessment]
Pancytopenia during FLT3-ITD positive AML induction-like therapy
Hematuria in thrombocytopenic, neutropenic patient
Infection risk and prophylaxis
Neurocognitive disorder and psychotropic regimen
Cardiopulmonary reserve and chemotherapy fitness
Transfusion logistics and caregiver concerns
[Plan / Recommendation]
Pancytopenia management and monitoring
Hematuria and bleeding risk
Infection prevention and anti-infective stewardship
Neurocognitive and psychiatric medication optimization
Transfusion logistics and care coordination
Medication review and polypharmacy
Caregiver education and follow-up
Follow-up
[Pancytopenia]
Pancytopenia in this patient is expected, multifactorial, and clinically significant. Key points include:
Summary:
[exam finding]
2025-11-24 CXR
2025-10-28 Pathology - kidney biopsy
2025-10-23, 2025-10-21, 2025-10-20, 2025-10-17, 2025-09-11 CXR
2025-10-17 ECG
2025-09-17 ECG
2025-09-17 2D transthoracic echocardiography
2025-09-16 CT - abdomen
2025-09-15 Sonography - abdomen
2025-06-23 ECG
2025-04-02 Transrectal Ultrasound of the Prostate, TRUS-P
2025-03-31 ECG
2025-03-31 CXR
2024-12-31 2D transthoracic echocardiography
2024-11-12 ECG
2024-10-23 Pathology - skin non-cyst/tag/debridement/plastic
2024-10-15 ECG
2024-10-15 CXR
[MedRec]
2025-10-13 SOAP Hemato-Oncology Liu YiSheng
2025-10-17 ~ 2025-11-06 POMR Hemato-Oncology Liu YiSheng
2025-10-20 MultiTeam - Palliative Care
2025-10-15 SOAP Urology Li MingWei
2025-09-11 ~ 2025-10-02 POMR Hemato-Oncology Liu YiSheng
2025-06-24 SOAP Cardiology Cai GuiDong
2024-11-27 SOAP Dermatology Wu RuoWei
[consultation]
2025-11-24 Cardiology
2025-11-01 Urology
2025-10-17 Family Medicine
2025-10-17 Cardiology
2025-09-17 Cardiology
[surgical operation]
2024-10-22
Patient: 曾健翔, 男, 1956-04-10
Problem 1. Acute on chronic heart failure with marked myocardial injury in a structurally abnormal heart
Problem 2. Stage IV clear cell renal cell carcinoma with diffuse lung metastases and prior HPV-related scrotal squamous cell carcinoma
Problem 3. Venous thromboembolism (renal vein, IVC, pulmonary embolism) vs bleeding risk under anticoagulation
Problem 4. Severe chronic normocytic anemia related to RCC, hematuria, chronic disease, and recent decompensation
Problem 5. Chronic kidney disease with recent functional decline and cardiorenal interaction
Problem 6. Persistent hyponatremia likely due to SIADH or hypervolemic HF, with mild to moderate severity
Problem 7. Symptom burden, functional decline, and integration of palliative/hospice care
Overall, the patient is in an advanced stage of both oncologic and cardiac disease, with rising biomarkers, worsening renal function, persistent anemia, and chronic hyponatremia. Given his DNR status and prior choice for hospice combined care, the overarching recommendation is to shift the center of gravity from disease modification to meticulous symptom control, thoughtful de-escalation of anticoagulation and non-essential medications, and proactive planning for a comfortable end-of-life trajectory.
Summary (2025-10-20)
Problem 1. ongoing myocardial injury/nstemi vs demand ischemia
Problem 2. pulmonary embolism with pulmonary hypertension and rv dysfunction
Problem 3. acute kidney injury on ckd stage 3 with hyponatremia and metabolic acidosis
Problem 4. chronic anemia of cancer with current critical low hemoglobin
Problem 5. malignancy of unknown primary, radiology favors metastatic rcc; biopsy planning and goals of care
Problem 6. medication safety: hypotension risk, vte risk with megestrol, and polypharmacy
Problem 7. nutrition, hypoalbuminemia, and general supportive care
Problem 8. benign prostatic hyperplasia symptoms on combination therapy
closing notes
[exam finding]
2025-11-23 CXR
2025-11-06 MRI - liver, spleen
2025-11-04 ECG
2025-11-04 CT - abdomen
2025-11-04 KUB
2025-11-03 CXR
2025-05-13 Bladder Sonograpy
2025-05-13 Uroflowmetry
2025-05-13 Transrectal Ultrasound of the Prostate, TRUS-P
2024-11-20 Bone densitometry - spine + hip
2024-10-24 EEG
2024-10-18 C-spine AP + Lat
[MedRec]
2025-11-14 SOAP Hemato-Oncology Yang MuJun
2025-11-05 ~ 2025-11-11 POMR Gastroenterology Chen HongDa
2025-10-31, 2025-08-08, 2025-05-16, 2025-02-21 SOAP Neurology Yang FuYi
2025-09-02, 2025-06-10 SOAP Urology Cai YaoZhou
2024-11-29 SOAP Neurology Yang FuYi
2024-09-06 SOAP Neurology Yang FuYi
2024-08-18 POMR Chest Medicine Wu ZhiWei
2024-01-26 SOAP Neurology Yang FuYi
Key Insights / Summary
Problem 1. Liver tumors with left adrenal metastasis (suspected HCC)
Problem 2. Cardiovascular status (CAD s/p stent, atrial fibrillation, CHF history)
Problem 3. Diabetes mellitus
Problem 4. Hematological status
Problem 5. Renal function and metformin management
Problem 6. Pain and functional status
Problem 7. Past neurological disease (old CVA, EEG abnormality)
[exam findings]
2025-11-16 CT - abdomen
2025-10-27 Esophagogastroduodenoscopy, EGD
2025-08-21 Sonography - abdomen
2025-05-15 Sonography - abdomen
2024-10-08 Sonography - abdomen
2024-08-08 Sonography - abdomen
2024-02-02 Sonography - abdomen
2023-10-05 Sonography - abdomen
2023-06-28 MRI - liver, spleen
2023-04-06 Sonography - abdomen
2023-01-12 MRI - liver, spleen
2022-07-07 Sonography - abdomen
2022-05-30 Pathology - gallbladder
2022-05-28 CT - abdomen
2022-05-26 Sonography - abdomen
2022-04-21 Esophagogastroduodenoscopy, EGD
2022-04-21 Endoscopic Retrograde Cholangiopancreatography, ERCP
2022-04-20 Sonography - abdomen
2022-04-19 Abdomen - Standing (Diaphragm)
2022-04-16 Ankle Bilat:
2022-04-09 Abdomen - Standing (Diaphragm)
2022-04-07 2D transthoracic echocardiography
2022-04-07 Endoscopic Retrograde Cholangiopancreatography, ERCP
2022-04-05 CT - abdomen
2021-03-23 Pathology - hemorrhoids
2018-04-09 Sonography - abdomen
2018-03-15 2D transthoracic echocardiography
2018-03-07 24hr Holtor
2018-01-25 Surgival Pathology Level IV
2018-01-25 Sonography - abdomen
[MedRec]
2025-11-13 SOAP Gastroenterology Xiao ZongXian
2025-07-10, 2025-05-15, 2024-08-08 SOAP Gastroenterology Xiao ZongXian
2024-10-31 ~ 2024-11-02 POMR Hemato-Oncology Gao WeiYao
2024-10-05 ~ 2024-10-09 POMR Hemato-Oncology Gao WeiYao
2024-05-28 ~ 2024-05-30 POMR Hemato-Oncology Gao WeiYao
2024-05-16, 2024-02-22, 2023-11-30 SOAP Gastroenterology Xiao ZongXian
2023-07-11 SOAP Gastroenterology Xiao ZongXian
2022-05-28 ~ 2022-05-30 POMR General and Gastroenterological Surgery Chen JiaHui
2022-04-19 ~ 2022-04-25 POMR Hemato-Oncology Gao WeiYao
2022-04-06 ~ 2022-04-14 POMR Hemato-Oncology Gao WeiYao
2022-02-25 ~ 2022-03-03 POMR Hemato-Oncology Gao WeiYao
2021-04-01 ~ 2021-04-11 POMR Hemato-Oncology Gao WeiYao
2021-02-04 ~ 2021-02-06 POMR Hemato-Oncology Gao WeiYao
2018-11-05 ~ 2018-11-08 POMR Hemato-Oncology Gao WeiYao
2018-04-07 ~ 2018-04-10 POMR Nephrology Lin DingYun
2018-01-23 ~ 2018-01-26 POMR Hemato-Oncology Gao WeiYao
[surgical operation]
2022-05-28
2021-03-23
[medication]
Voydeya (danicopan) Q8H PO
Ultomiris (ravulizumab)
Soliris (eculizumab)
2025-07-24 - 600mg IVD OPD
2025-07-10 - 600mg IVD OPD
2025-06-26 - 600mg IVD OPD
2025-06-12 - 600mg IVD OPD
….-..-.. - continuing
2024-10-31 - 900mg IVD IPD
2024-05-29 - 900mg IVD IPD
2022-04-14 - 900mg IVD IPD
2022-03-03 - 900mg IVD IPD
2021-04-02 - 900mg IVD IPD
2021-02-04 - 900mg IVD IPD
….-..-.. - continuing
2018-07-24 - 600mg IVD OPD
2018-07-17 - 600mg IVD OPD
2018-07-10 - 600mg IVD OPD
2018-07-03 - 600mg IVD OPD
羅國芳, 0983-374-375
[Differential Diagnosis Derived Exclusively from Laboratory Findings]
Summary
[Differential Diagnosis Derived Exclusively from Laboratory and Examination Findings]
Overall synthesis
[Dx, Tx]
Diagnosis – integrated view
Treatment so far – what has been done and how effective
My insight – how I interpret the whole picture
My plan – what I would recommend focusing on now
Key insights / summary (2025-11-20)
Problem 1. Left lower lobe pneumonia (suspected atypical component), improving but still under treatment
Problem 2. Paroxysmal nocturnal hemoglobinuria with recent hemolytic flare under ravulizumab + Voydeya (danicopan)
Problem 3. Thrombocytopenia, thrombosis and bleeding risk management in PNH with acute infection
Problem 4. Renal and hepatic function under chronic PNH and recent hemolysis
Problem 5. Global supportive care, functional status, and discharge planning
[MedRec]
2025-11-13 SOAP Cardiology Xie JianAn
2025-10-21 ~ 2025-11-08 ~ 2022-04-25 POMR Chest Medicine Huang JunYao
2022-04-21 ~ 2022-04-25 POMR Chest Medicine Huang JunYao
2021-10-30 ~ 2021-11-13 POMR General and Gastroenterological Surgery Zhang YaoRen
2021-07-29 ~ 2021-07-31 POMR General and Gastroenterological Surgery Zhang YaoRen
2020-11-03 ~ 2020-11-19 POMR Chest Medicine Huang JunYao
2020-10-03 ~ 2020-10-16 POMR Infectious Disease Yang QinHui
[exam finding]
2025-08-22 ECG
2025-08-22 2D transthoracic echocardiography
2025-07-28 Sonography - breast
2025-07-28 2D transthoracic echocardiography
2025-07-18 PET
2025-06-06 Sonography - abdomen
2025-04-18 Sonography - breast
2025-02-27 2D transthoracic echocardiography
2025-02-24 MRI - breast
2025-02-07 MRA - brain
2025-02-04 Sonography - gynecology
2024-11-05 Nasopharyngoscopy
2024-11-04 Sonography - abdomen
2024-11-04 Sonography - gynecology
2024-10-30 2D transthoracic echocardiography
2024-10-25 CT
2024-10-22 PET
2024-10-21 Pap’s Smear
2024-10-08 Pathology - lymphnode biopsy
2024-10-08 Pathology - breast biopsy (no need margin)
2024-10-01 Sonography - breast
2018-05-22 Pathology
[MedRec]
2025-11-14 ~ 2025-11-15 POMR General and Gastrointestinal Surgery Li ChaoShu
2024-10-30 ~ 2024-11-06 POMR General and Gastrointestinal Surgery Li ChaoShu
2025-10-03 SOAP General and Gastrointestinal Surgery Li ChaoShu
2018-05-21 ~ 2018-05-25 POMR Plastic and Reconstructive Surgery Zhang MengZong
[surgical operation]
2024-10-28
2018-05-22
[chemotherapy]
2025-11-14 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min
2025-10-24 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min
2025-07-28 - Phesgo (pertuzumab 1200mg, trastuzumab 600mg; 10mL) ST SC 8min
2025-06-27 - Agifutol (glutathione) 1500mg NS 200mL 20min + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr
2025-06-06 - Agifutol (glutathione) 1500mg NS 200mL 20min + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr
2025-05-09 - Agifutol (glutathione) 1500mg NS 200mL 20min + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr
2025-04-18 - Agifutol (glutathione) 1500mg NS 200mL 20min + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr
2025-03-28 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min
2025-03-04 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min
2025-02-04 - Agifutol (glutathione) 1500mg NS 200mL 20min + Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min + docetaxel 75mg/m2 100mg NS 250mL 1hr
2025-01-03 - Agifutol (glutathione) 1500mg NS 200mL 20min + Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min + docetaxel 75mg/m2 100mg NS 250mL 1hr
2024-12-13 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min
2024-11-22 - Agifutol (glutathione) 1500mg NS 200mL 20min + Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min + docetaxel 75mg/m2 100mg NS 250mL 1hr
2024-10-30 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min + docetaxel 75mg/m2 100mg NS 250mL 1hr
[Medication]
Femara (letrozole 2.5mg) 1# QD
pegfilgrastim 6mg SC
G-CSF (filgrastim) 150mcg SC
Zoladex LA Depot (goserelin 10.8mg) SC
[Subjective]
Pharmacist–patient encounters related to Femara and bone health
[Objective]
Oncologic diagnosis, current therapy, and organ function
[Assessment]
Pharmacist’s problem list and clinical interpretation (as of 2025-11-19)
[Plan / Recommendation]
Pharmacist recommendations and potential improvements (as of 2025-11-19)
Key insights / summary (as of 2025-11-17)
Problem 1. Metastatic HER2-positive, hormone receptor–positive left breast carcinoma under ongoing systemic therapy
Problem 2. Bone metastases and skeletal-related event prevention
Problem 3. Cardiac function and arrhythmia under HER2-targeted therapy and prior anthracycline exposure
Problem 4. Indeterminate hepatic lesion(s) and fatty liver
Problem 5. Gynecologic conditions (uterine myoma, suspected adenomyosis) in the context of ovarian suppression
Problem 6. Hematologic status and myelosuppression under chemotherapy with growth factor support
Problem 7. Past and intercurrent infections / ENT and vulvar issues
Problem 8. Neurosurgical/vascular consideration: cavernoma in right posterior pons
Potential Medication Issues
[exam finding]
2025-10-23 CT - abdomen
2025-10-01 CXR
2025-09-29 Abdomen - Standing (Diaphragm)
2025-09-23 KUB
2025-09-28 ECG
[MedRec]
2025-11-13 SOAP Hemato-Oncology Gao WeiYao
2025-09-29 ~ 2025-10-07 POMR Hemato-Oncology Gao WeiYao
2025-08-29 SOAP Hemato-Oncology Gao WeiYao
2025-08-01 ~ 2025-08-07 POMR Hemato-Oncology Gao WeiYao
[surgical operation]
2025-08-05
[chemotherapy]
Key insights / summary
Problem 1. Metastatic gastric carcinoma with peritoneal and suspected Krukenberg metastasis under FLOT plus Nivolumab (Opdivo, nivolumab)
Problem 2. Chemotherapy-related anemia and thrombocytopenia
Problem 3. Electrolyte balance and history of hypokalemia
Problem 4. Infection risk and prior febrile episode under chemotherapy
Problem 5. Hepatic function and HBV reactivation risk under chemo-immunotherapy
Problem 6. Renal function and hydration status
Problem 7. Nutritional status and prior weight loss
Problem 8. Cardiovascular status with prior enlarged cardiac silhouette and PACs
Problem 9. Depression and psychosocial issues
Problem 10. History of proximal transverse colon cancer status post right hemicolectomy
Potential Medication Issues
[exam finding]
2025-11-11 CXR
2025-11-11 ECG
2025-11-06 2D transthoracic echocardiography
2025-11-04 KUB
2025-10-30 Tc-99m MDP bone scan
2025-10-13 CXR
2025-10-13 ECG
2025-10-09 MRI - brain
2025-10-01 CT - brain
2025-09-03 ECG
2025-09-01 CT - abdomen
2025-08-26 Sonography - breast
2025-08-26 Mammography
2025-08-26 2D transthoracic echocardiography
2025-08-19 Pathlogy (Y1)
2025-08-19 Pathlogy
2025-08-18 Sonography - abdomen
2025-06-17 Bone densitometry - spine + hip
2025-06-02 CT - chest
2025-03-10 CT - chest
2025-03-10 CT - abdomen
2025-03-03 Sonography - abdomen
2024-12-12 PET
2024-11-21 2D transthoracic echocardiography
2024-10-24 Pathology - soft tissue debridement
2024-10-21 CXR
2024-09-11 Sonography - abdomen
2024-08-29 Pathology - lymph node region resection
2024-08-22 MRI - breast
2024-08-21 CXR
2024-08-21 ECG
2024-08-20
Breast, right, core needle biopsy — Benign breast tissue with microcalcification
2024-07-26 2D transthoracic echocardiography
2024-05-07 PET
2024-04-29 2D transthoracic echocardiography
2024-03-27 Sonography - abdomen
2024-01-02 2D transthoracic echocardiography
2023-12-20 Sonography - abdomen
2023-12-19 PET
2023-12-07 ECG
2023-11-30 Tc-99m MDP bone scan
2023-11-22 CT - brain
2023-11-21 Pathology - breast biopsy (no need margin)
2023-11-21 Pathology - breast biopsy (no need margin)
[MedRec]
2025-10-17 MultiTeam - Psychosocial oncology
2025-10-15 MultiTeam - Social services
2025-10-14 MultiTeam - Palliative Care
2025-10-13 ~ 2025-11-11 POMR General and Gastroenterological Surgery Chen JiaHui
[consultation]
2025-10-14 Neurosurgery
2025-10-14 Radiation Oncology
2023-12-08 Gastroenterology
[surgical operation]
2024-10-23
2024-08-28
2024-08-28
2023-12-08
[immunochemotherapy]
2025-11-05 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 300mg D5W 100mL 90min
2025-10-15 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
2025-09-02 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 260mg NS 250mL 90min
2025-08-12 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 260mg NS 250mL 90min
2025-07-22 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 270mg NS 250mL 90min
2025-06-30 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 270mg NS 250mL 90min
2025-06-02 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 270mg NS 250mL 90min
2025-05-05 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 270mg NS 250mL 90min
2025-04-14 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 273mg NS 250mL 90min
2025-03-03 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 270mg NS 250mL 90min
2025-02-10 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 190mg NS 250mL 90min
2025-01-21 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 275mg NS 250mL 90min
2025-01-02 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/m2 275mg NS 250mL 90min
2024-12-11 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr
2024-11-20 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr
2024-10-30 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr
2024-10-09 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr
2024-07-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1090mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr
2024-07-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1095mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr
2024-06-14 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1094mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr
2024-05-20 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1097mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr
2024-04-29 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 136mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
2024-04-08 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
2024-03-15 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 134mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
2024-02-21 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
2024-01-24 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 131mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
2024-01-02 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 128mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
2023-12-08 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 840mg NS 250mL 1hr + docetaxel 75mg/m2 128mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
[medication]
Femara (letrozole 2.5mg) 1# QD
G-CSF (filgrastim) 150mcg SC
Bio-Cal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU)
[lab data]
2025-06-02 Bone Marrow Chromosome Analysis
[exam finding]
2025-11-12 CXR
2025-10-31 CXR
2025-10-27 Pleural Tapping
2025-10-24 CXR
2025-10-18, 2025-10-16 CXR
2025-10-17 Sonography - abdomen
2025-10-16 Mycobacterium tuberculosis complex molecular detection
2025-10-13 Pathology - spleen
2025-10-08 CT - abdomen
2025-10-07 Sonography - abdomen
2025-10-02 2D transthoracic echocardiography
2025-09-30
2025-09-19 Pathology - spleen
2025-09-18 CT - chest
2025-06-11 Pathology - bone marrow biopsy
2025-05-23 MRI - C-spine
2025-05-15 C-spine AP+ Lat.
2025-05-15 2D transthoracic echocardiography
2025-05-14 Nasopharyngoscopy
2025-05-13 Pathology - bone marrow biopsy
[MedRec]
2025-10-31 SOAP Hemato-Oncology Yang MuJun
2025-09-16 ~ 2025-10-28 POMR Hemato-Oncology Yang MuJun
2025-05-21 MultiTeam - Psychosocial Oncology
2025-05-12 ~ 2025-06-11 POMR Hemato-Oncology Yang MuJun
[surgical operation]
2025-10-10
[chemotherapy]
[note]
FLAG-IDA - 2025-11-14 - https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-54-flag-ida.pdf
Acute myeloid leukaemia FLAG-Ida (fludarabine cytarabine iDArubicin and filgrastim) - 2025-11-14 - https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/347-acute-myeloid-leukaemia-flag-ida-fludarabine
Key insights / summary
Problem 1. High-risk AML status, possible relapse / extramedullary disease and transplant planning
Problem 2. Complex infectious history, current cough and residual pulmonary / pleural disease
Problem 3. Post-splenectomy state and residual splenic/liver lesions
Problem 4. Hematological status: pancytopenia, transfusion dependence, hyperferritinemia
Problem 5. Chronic hepatitis B with high HBsAg, on entecavir prophylaxis
Problem 6. Electrolyte and fluid balance: hyponatremia, hypokalemia, mild metabolic parameters
Problem 7. Cardiopulmonary function: diastolic dysfunction, pericardial effusion, pleural effusion, blood pressure
Problem 8. Symptom control: cough, skin lesions, psychosocial issues
Potential Medication Issues
Why not recommend to use Jadenu (deferasirox) immediately?
Why HCT schedule matters for Jadenu (deferasirox) ?
HCT schedule matters for Jadenu (deferasirox) - evidence based.
[exam finding]
2025-10-29 IMMUNOHISTOCHEMICAL STUDY
2025-10-21 CXR
2025-10-09 CXR
2025-10-02 PET
2025-10-01 CXR
2025-09-30 RAS & BRAF V600 MassArray
2025-09-30 CT - abdomen
2025-09-24 Endoscopic Retrograde Cholangiopancreatography, ERCP
2025-09-16 Upper GI Series
2025-09-10 Pathology
2025-09-10 Pathology
2025-09-08 Endoscopic Retrograde Cholangiopancreatography, ERCP
2025-09-04 CT - abdomen
2025-08-29 Abdomen - standing (diaphragm)
2025-08-28 Pathology - liver biopsy needle/wedge
2025-08-28 Sonography - abdomen
2025-08-27 CXR
2025-08-26 Endoscopic UltraSound, EUS
2025-08-25 CT - abdomen
2025-08-25 Sonography - abdomen
2025-08-18 Sonography - abdomen
2025-08-13 Esophagogastroduodenoscopy, EGD
2025-08-12 Esophagogastroduodenoscopy, EGD
2025-07-28 Pathology - colon biopsy
2025-07-28 CXR
2025-07-25 CT - abdomen
2025-07-25 Colonoscopy
2025-07-25 Esophagogastroduodenoscopy, EGD
2025-07-18 Esophagogastroduodenoscopy, EGD
2025-07-17 ECG
2025-07-15 2D transthoracic echocardiography
2025-07-14 CXR
2025-07-13 CT - abdomen
[MedRec]
2025-11-07 SOAP Hemato-Oncology Yang MuJun
2025-10-28 ~ 2025-11-01 POMR Hemato-Oncology Yang MuJun
2025-10-17 SOAP Gastroenterology Zhan WeiYu
2025-10-17 SOAP Hemato-Oncology Yang MuJun
2025-07-13 ~ 2025-10-11 POMR Gastroenterology Zhan WeiYu
[surgical operation]
2025-10-21
2023-01-13
[immunochemotherapy]
Key insights / summary
Problem 1. Metastatic colorectal adenocarcinoma (proximal ascending colon) with liver metastasis, KRAS-mutant, pMMR, HER2 negative
Problem 2. Recent necrotizing pancreatitis with walled-off necrosis and MPD disruption, now post-interventions
Problem 3. Anemia (symptomatic risk with Hgb 8.9 g/dL) during chemotherapy
Problem 4. Electrolyte and mineral abnormalities: hypocalcemia with low–normal magnesium; history of hypomagnesemia
Problem 5. Infection history and current risk under chemotherapy (prior Enterobacter bacteremia; Candida UTI)
Problem 6. Cardiovascular status with prior atrial fibrillation, concentric LVH, and bevacizumab exposure
Problem 7. Chronic pleural disease and intrathoracic goiter with tracheal deviation
Problem 8. Gastro-duodenal ulcer disease, now quiescent
Problem 9. Nutrition decline and weight loss
Problem 10. Ophthalmologic issues (low vision left eye; visual loss right eye)
Medication and supportive care reconciliation highlights (as of 2025-11-13)
Follow-up and timing summary
Potential Medication Issues
[exam finding]
2025-11-12 MRI - pancreas
2025-11-11 2D transthoracic echocardiography
2025-11-11 Esophagogastroduodenoscopy, EGD
2025-11-10 Abdomen Decubitus Lt
2025-11-10, 2025-11-09, 2025-11-04 CXR
2025-11-10 09:58 ECG
2025-10-27 ECG
2025-10-26 KUB
2025-10-26 CXR
2025-10-20 MRI (done at TMUH, documented on 2025-10-21 SOAP)
[MedRec]
2025-11-13 MultiTeam - Wound Care
2025-11-11 Shared Decision Making, SDM - Family Meeting
2025-11-10 Shared Decision Making, SDM - Family Meeting
2025-10-28 MultiTeam - Wound Care
2025-10-21 SOAP Hemato-Oncology Xia HeXiong
2025-10-07 SOAP Hemato-Oncology Xia HeXiong
2025-10-03 SOAP General and Gastroenterological Surgery Wu Chaoqun
[chemotherapy]
Key insights / summary
Problem 1. Ongoing sepsis from polymicrobial biliary / urinary / pulmonary sources under complex antibiotic therapy
Problem 2. Locally advanced pancreatic head adenocarcinoma with obstructive jaundice, dual PTCD drainage and recent Gemcitabine / nab-paclitaxel
Problem 3. Acute on chronic kidney disease under nephrotoxic exposures
Problem 4. Anemia, thrombocytopenia and gastrointestinal bleeding risk under chemotherapy and anticoagulation-free state
Problem 5. Electrolyte, nutritional and metabolic derangements (hyponatremia, borderline hypokalemia, hypocalcemia, hypoalbuminemia, metabolic acidosis)
Problem 6. Cardiopulmonary status: diastolic dysfunction, elevated NT-proBNP, pleural effusion, arrhythmia risk and prior respiratory failure
Problem 7. Type 2 diabetes mellitus with variable glycemic control under infection and intermittent insulin use
Problem 8. Neurologic comorbidities (recent PCA and frontal infarctions with seizures) and cognitive / functional implications
Problem 9. Pressure injury, deconditioning and palliative care / goals-of-care alignment
[exam finding]
2025-10-02 CXR
2025-10-01 Antegrade Venography
2025-09-02 Pathology - uterus (with or without SO) neoplastic
2025-08-13 CT - abdomen
2025-08-13 Sonography - gynecology
2025-05-08 Pap’s Smear
2025-05-07 Sonography - gynecology
[MedRec]
2025-09-30 ~ 2025-10-03 POMR Hemato-Oncology Lin YiTing
2025-08-28 ~ 2025-09-11 POMR Obstetrics and Gynecology Huang SiCheng
[surgical operation]
2025-10-20
2025-09-10
2025-09-01
2024-01-11
2022-12-22
[chemotherapy]
Key insights / summary (as of 2025-11-12)
Problem 1. Ovarian clear cell carcinoma, stage IC, post-optimal debulking, on adjuvant carboplatin + paclitaxel (Abraxane)
Problem 2. Possible asymptomatic bacteriuria vs early UTI before chemotherapy
Problem 3. Chemotherapy-associated anemia, normocytic, mild
Problem 4. HBV exposure/risk under cytotoxic chemotherapy
Problem 5. Central venous access (Port-A; prior PICC), function after revision
Problem 6. Anticipated chemotherapy toxicities (neuropathy, myelosuppression, hypersensitivity, CINV, constipation)
Problem 7. Cardiometabolic comorbidities and concomitant medications
Problem 8. Organ function and electrolytes (currently acceptable)
Medication reconciliation (current, per records)
Potential Medication Issues
[exam finding]
2025-11-08 CT - abdomen
2025-08-29 PET
2025-08-28 Pathology - soft tissue biopsy / simple ecision (non-lipoma)
2025-08-13 CT - abdomen
2025-08-12 Kidney Sonography - urology
2025-06-12 CT - chest
2025-01-09 Kidney Sonography - urology
2024-12-24 CT - abdomen
2024-12-12 CT - chest
2024-09-07 MRI - brain
2024-09-06 Tc-99m MDP bone scan
2024-09-05 PET
2024-08-21 Pathology - lung total/lobe/segmental
2024-07-31 Flow volume chart
2024-07-30 CT - chest
2024-06-17 CT - abdomen
2024-04-30 CT - chest
XXXX-XX-XX
2023-12-04 Pathology - urinary bladder partial/total resection
XXXX-XX-XX
2023-07-21 Pathology - urinary bladder biopsy
2023-07-19 Tc-99m MDP bone scan
[MedRec]
2025-10-10 ~ 2025-10-17 POMR Urology Cai YaoZhou
2025-08-27 ~ 2025-09-03 POMR Urology Cai YaoZhou
2025-01-10 ~ 2025-01-15 POMR Urology Cai YaoZhou
2024-09-01 ~ 2024-09-07 POMR Thoracic Surgery Xie MinXiao
2024-08-20 ~ 2024-08-29 POMR Thoracic Surgery Xie MinXiao
2024-03-19 ~ 2024-04-12 POMR Urology Cai YaoZhou
2023-11-29 ~ 2024-01-11 POMR Urology Cai YaoZhou
2023-07-18 ~ 2023-07-22 POMR Urology Cai YaoZhou
[consultation]
[surgical operation]
2025-08-28
2024-08-21
2024-03-20
2024-01-03
2023-12-19
2023-12-01
2023-08-11
2023-07-21
[immunochemotherapy]
[note]
Enfortumab vedotin Adult Dosing - 2025-11-12 - https://www.uptodate.com/contents/enfortumab-vedotin-drug-information
[Subjective]
Pharmacist follow-up
Treatment trajectory context (for reconciliation)
[Objective]
Recent labs and vitals surrogate (most recent available)
Current anticancer medications and premedications (per infusion logs)
[Assessment]
Medication- and treatment-focused evaluation (2025-11-12)
Potential improvements in care
[Plan / Recommendation]
Safety monitoring and labs
Dermatologic prophylaxis and early intervention
Stoma/port skin and infection prevention
UTI stewardship pathway for ileal conduit
Neuropathy and ocular monitoring while on EV
Electrolyte and metabolic measures
Pain control and supportive care
Patient/caregiver education and access
Follow-up and documentation
Key insights/summary (2025-11-12)
Problem 1. Recurrent urothelial carcinoma, pelvic lesion, on EV + pembrolizumab
Problem 2. Treatment-related dermatologic toxicity and port/cystostomy ulcerations
Problem 3. Recurrent urinary tract infection and pyuria with ileal conduit
Problem 4. Immune-related endocrinopathies surveillance while on PD-1
Problem 5. Organ function and treatment fitness (renal, hepatic, hematologic, coagulation)
Problem 6. Electrolyte balance and metabolic monitoring on EV
Problem 7. Cancer pain and analgesic optimization
Problem 8. Prior lung adenocarcinoma (pT1miN0M0) surveillance
Problem 9. Gallbladder microlithiasis and abdominal postoperative changes
Problem 10. Vaccination, infection prevention, and supportive care during immunochemotherapy
Potential Medication Issues
[exam finding]
2025-11-05 PET
[MedRec]
2025-11-04 ~ 2025-11-08 POMR General and Gastroenterological Surgery Wu ChaoQun
2025-04-08 SOAP Hemato-Oncology Xia HeXiong
2025-04-08 SOAP General and Gastroenterological Surgery Wu ChaoQun
[surgical operation]
2025-11-06
[Subjective]
Cancer-related symptoms and treatment course (2025-11-12)
Medication-related narrative (2025-11-12)
[Objective]
Oncologic status and procedures
Laboratory data and markers (2025-11-04 unless stated)
Current analgesic exposure estimate (2025-11-12)
Functional considerations
[Assessment]
Cancer-related pain, currently suboptimally controlled
Sleep disturbance (insomnia), persistent
Deconditioning and sarcopenia risk due to reduced mobility from ankle fracture
Oral mucositis and alopecia, improved
Oncologic trajectory and marker context
[Plan / Recommendation]
Analgesia optimization and safety (to discuss with doctor at next visit)
Sleep disturbance
Mobility, rehabilitation, and thrombosis risk reduction
Oral care and supportive measures
Coordination and monitoring
Medications explicitly referenced in this note
Key insights/summary
Problem 1. Pancreatic adenocarcinoma with persistent arterial encasement after neoadjuvant therapy (unresectable/locally advanced)
Problem 2. Suspicious right supraclavicular lymph node (possible M1 disease)
Problem 3. Postoperative/post-procedural pain and supportive care
Problem 4. Tumor markers and disease monitoring strategy
Problem 5. Perioperative risk, organ function, and treatment fitness
Medications mentioned in chart
Notes for immediate actions (next clinic visit)
[exam findings]
2025-10-17 CT - abdomen
2025-09-25 CXR
2025-09-25 Pathology - lung wedge biopsy
2025-08-12 2D transthoracic echocardiography
2025-08-11 CXR
2025-08-11 Pathology - lung transbronchial biopsy
2025-08-08 CT - abdomen
2025-08-06 EsophagoGastroDuodenoscopy, EGD
2025-06-26 Pathology - lung transbronchial biopsy
2025-06-26 CXR
2025-04-23 CT - abdomen
2025-01-24 CT - abdomen
2024-11-15 Colonoscopy
2024-11-11 CT - abdomen
2024-11-11 KUB
2024-10-30 CXR
2024-10-30 Esophagogastroduodenoscopy (EGD)
2024-10-26 CT - abdomen
2024-10-24 CXR
2024-07-22 CXR
2024-06-27 Tc-99m MDP bone scan
2024-06-26 CXR erect
2024-04-30 CT - abdomen
2024-04-18, 2024-02-16 Embolization (TAE) - abdomen for tumor
2024-02-15 MRI - liver, spleen
2024-01-19 Embolization (TAE) - abdomen for tumor
2023-12-19 ECG
2023-12-08 CT - abdomen
2023-11-03 Embolization (TAE) - abdomen for tumor
2023-11-02 CT - abdomen
2023-10-13 Embolization (TAE) - abdomen for tumor
2023-10-04 Acoustic Radiation Force Impulse (ARFI)
2023-10-04 SONO - abdomen
2023-09-08 Embolization (TAE) - abdomen for tumor
2023-08-29 MRI - liver, spleen
2023-08-23 CT - abdomen
[MedRec]
2025-10-22 ~ 2025-10-24 POMR Hemato-Oncology Xia HeXiong
2025-10-21 SOAP Hemato-Oncology Xia HeXiong
2025-10-21 SOAP Hemato-Oncology Xia HeXiong
2025-10-06 ~ 2025-10-08 POMR Hemato-Oncology Xia HeXiong
2025-08-27 ~ 2025-08-30 POMR Hemato-Oncology Xia HeXiong
2025-07-06 ~ 2025-07-08 POMR Hemato-Oncology Xia HeXiong
2024-11-12 ~ 2024-11-22 POMR Hemato-Oncology Xia HeXiong
2024-10-25 ~ 2024-11-07 POMR Hemato-Oncology Xia HeXiong
2024-09-26 ~ 2024-09-27 POMR Hemato-Oncology Xia HeXiong
2024-09-12 SOAP Dermatology Wu RuoWei
2024-08-23 ~ 2024-08-24 POMR Hemato-Oncology Xia HeXiong
2024-08-14 SOAP Dermatology Wu RuoWei
2024-08-07 SOAP Dermatology Wu RuoWei
2024-07-22 ~ 2024-07-25 POMR Hemato-Oncology Xia HeXiong
2024-06-26 ~ 2024-06-29 POMR Hemato-Oncology Xia HeXiong
2024-06-18 SOAP Hemato-Oncology Xia HeXiong
2024-04-17 ~ 2024-04-19 POMR General and Gastroenterological Surgery Wu ChaoQun
2023-09-07 POMR General and Gastroenterological Surgery Wu ChaoQun
[consultation]
2024-04-17 Diagnostic Radiology
2024-01-20 Diagnostic Radiology
2023-11-03 Diagnostic Radiology
2023-10-13 Diagnostic Radiology
2023-09-08 Diagnostic Radiology
[radiotherapy]
[immunochemotherapy]
[medication]
Cabometyx (cabozantinib 40mg) 1# QDAC (self-paid)
Vemlidy (tenofovir alafenamide 25mg) 1# QD
Baraclude (entecavir) QDAC (self-paid)
Lenvima (lenvatinib 10mg) 1# QD
Key Insight/Summary
Problem 1. Progressive HCC with portal vein tumor thrombosis and lung metastases
Problem 2. Portal-hypertensive state with ascites and esophageal varices
Problem 3. Severe thrombocytopenia with leukopenia and anemia
Problem 4. Worsening cholestasis and hepatocellular injury
Problem 5. Chronic HBV infection under antiviral prophylaxis
Problem 6. Cancer-related symptoms and supportive care
Problem 7. Cardiopulmonary and renal status
Active Medication Reconciliation (2025-11-10~2025-11-11 admissions)
Follow-up and Monitoring Plan
[Potential Medication Issues]
Key insight/summary
Problem 1. Cabometyx (cabozantinib) in worsening hepatic function
Problem 2. Hypertension risk from Cabometyx with existing borderline hypertension
Problem 3. Severe thrombocytopenia and bleeding risk during Cabometyx therapy
Problem 4. Ascites regimen suboptimal and short-course albumin-furosemide bridging only
Problem 5. Drug–drug risk: morphine with lorazepam and cirrhosis-related sensitivity
Problem 6. Acid suppression and upper GI risk management
Problem 7. HBV reactivation prevention during TKI therapy
Problem 8. Prokinetic and Cabometyx: potential QT/electrolyte-related risk
Problem 9. Proteinuria/renal adverse effect monitoring during Cabometyx and diuretics
Problem 10. Anemia management amid ongoing therapy
Immediate next steps (from 2025-11-11)
Patient Summary:
Problem 1. Recurrent HCC with Lung Metastases
Problem 2. Leukopenia and Immune Status
Problem 3. Gastrointestinal Complications
Problem 4. Electrolyte Balance and Renal Function
[potential drug-induced thrombocytopenia]
Historical lab data shows a long-term decline in platelet levels. The patient’s treatment with atezolizumab and bevacizumab overlaps with this period, so the influence of these medications cannot be ruled out. Literature reports an incidence of immune thrombocytopenia of less than 1% with atezolizumab, while bevacizumab is associated with a much higher incidence of thrombocytopenia (58%; grades 3/4: 20% to 40%).
If clinically judged to be at risk of bleeding, a platelet transfusion might be considered.
The current treatment regimen has been switched to durvalumab, which has also been reported to cause immune thrombocytopenia. Please continue to monitor platelet levels.
[Avodart (dutasteride 0.5 mg/capsule) tube feeding]
Avodart (dutasteride 0.5 mg/capsule) is not formulated for tube administration, as it is a liquid-filled capsule. For alternative treatment, Propecia (1 mg finasteride tablets) is currently stocked. Note that, according to the WHO ATC/DDD index (G04CB), 0.5 mg of dutasteride is pharmacologically equivalent to 5 mg of finasteride, which may be relevant if the treatment indication is Benign Prostatic Hyperplasia (BPH).
[exam finding]
2025-07-07 CT - chest
2025-05-26 Microsonography
2025-05-14 CXR
2025-05-02 ECG
2025-04-29, 2025-04-27 CXT
2025-03-17 ECG
2025-03-17 CXR
2025-03-07 Pathology - liver biopsy needle/wedge
2025-03-05 Tc-99m MDP bone scan with SPECT
2025-03-03 MRI - liver, spleen
2025-03-01 CT - chest
2025-02-27 ECG
2025-02-22 CT - abdomen
2025-02-19 Sonography - abdomen
2025-02-18 CXR
2025-02-17 2D transthoracic echocardiography
2025-02-15 19:06 ECG
2025-02-15 15:38 ECG
2025-02-10 Transrectal Ultrasound of Prostate (TRUS-P)
2025-02-10 Sonography - urology
2025-02-10 Bladder Sonography
[MedRec]
2025-05-18 ~ 2025-05-20 POMR Hemato-Oncology Yang MuJun
2025-02-27 ~ 2025-03-08 POMR Gastroenterology Chen HongDa
2025-02-15 ~ 2025-02-22 POMR Integrative Medicine Hong BoBin
[consultation]
2025-05-19 Metabolism and Endocrinology
2025-05-05 Oral and Maxillofacial Surgery
2025-04-28 Dermatology
2025-03-04 Hemato-Oncology
2025-02-27 Cardiology
2025-02-27 Chest Medicine
2025-02-20 Gastroenterology
[immunochemotherapy]
Key insights / summary (as of 2025-11-10)
Problem 1. Suspected bacterial sepsis of unclear source
Problem 2. Acute kidney injury on CKD3 with cumulative cisplatin exposure
Problem 3. Thrombocytopenia and anemia, likely treatment-related, with concurrent aspirin use
Problem 4. Hyperglycemia with type 2 diabetes and infection stress
Problem 5. Electrolyte abnormalities and nutrition
Problem 6. Metastatic intrahepatic cholangiocarcinoma on pembrolizumab + gemcitabine/cisplatin
Problem 7. Atrial fibrillation with moderate–severe MR and HFpEF
Problem 8. Chronic hepatitis B on antiviral prophylaxis
Problem 9. Medication reconciliation and safety
Follow-up and monitoring plan
[Potential Medication Issues]
Yes — there are guideline- or consensus-type publications that address antiplatelet therapy in thrombocytopenia, though none give a universally firm threshold of “stop aspirin at <100k” in all scenarios. Key relevant evidence:
So in summary:
Given your patient’s platelet count (~58k/µL) plus bleeding risk (chemotherapy, cirrhosis, thrombocytopenia) the decision to hold aspirin is consistent with these guideline-informed risk/benefit considerations despite the absence of a rigid number in the guideline texts.
Ref:
Patient Evaluation
Problem 1. Intrahepatic cholangiocarcinoma with lung and bone metastases
Problem 2. Renal dysfunction and electrolyte balance
Problem 3. Anemia and bone marrow suppression
Problem 4. Type 2 diabetes mellitus with poor glycemic control
Problem 5. Cardiovascular comorbidity: atrial fibrillation and mitral regurgitation
This is a 73-year-old man with intrahepatic cholangiocarcinoma (ICC) with lung and bone metastases, underlying liver cirrhosis (Child-Pugh A), atrial fibrillation, hypertension, type 2 diabetes mellitus, and prior stroke. He was admitted for Port-A insertion and first-time chemotherapy. He has declined lung biopsy but underwent a CT-guided liver biopsy confirming adenocarcinoma consistent with cholangiocarcinoma.
Recent workup shows: - Liver tumor (4.9 cm, S2-3), multiple lung nodules, bone lesions (rib cage, T-spine) - Atrial fibrillation with slow ventricular response, moderate-to-severe mitral regurgitation - Elevated HBV DNA (950,000 IU/mL) and now on Vemlidy (tenofovir alafenamide) - Mildly reduced renal function (eGFR 62.48 mL/min/1.73m²) - Borderline low sodium (134 mmol/L) - Recent imaging suggests possible early lung metastases and progressive hepatic disease
Problem 1: Intrahepatic Cholangiocarcinoma with Lung and Bone Metastases (Stage IV)
Problem 2: Hepatitis B Virus (HBV) Reactivation Risk
Problem 3: Atrial Fibrillation and Valvular Heart Disease
Problem 4: Lung Nodules – Metastatic vs. Primary?
Problem 5: Bone Lesions – Metastatic vs. Degenerative?
Final Treatment Plan Summary
[Comparison of “Durvalumab + Gemcitabine + Cisplatin”, “Pembrolizumab + Gemcitabine + Cisplatin”, and “Gemcitabine + Cisplatin” in This BTC Patient]
Background & Context
Efficacy Comparison
| Regimen | Overall Survival (OS) | Progression-Free Survival (PFS) | Key Clinical Trial |
|---|---|---|---|
| GemCis | 11.7 months (median) | 5.7 months (median) | ABC-02 Trial |
| D-GemCis | 12.8 months (median) | 7.2 months (median) | TOPAZ-1 Trial |
| P-GemCis | 12.7 months (median) | Not significantly different | KEYNOTE-966 Trial |
Safety and Toxicity Profile
| Regimen | Common Adverse Effects | Immune-Related Adverse Events (irAEs) |
|---|---|---|
| GemCis | Neutropenia, anemia, fatigue, nausea, hepatotoxicity | None |
| D-GemCis | Similar to GemCis | Mild to moderate immune-related toxicities (e.g., hepatitis, colitis, thyroiditis, pneumonitis) |
| P-GemCis | Similar to GemCis | Immune-related toxicities, potential for severe irAEs |
Do We Need PD-L1 Testing Before Immunotherapy? (below not posted)
Considerations for This Specific Patient
Final Treatment Recommendation
Summary Table of Recommendations
| Treatment Plan | Recommended for This Patient? | Rationale |
|---|---|---|
| D-GemCis | Preferred choice | Best survival benefit, minimal added toxicity |
| P-GemCis | Alternative option | Good survival benefit, slightly less robust PFS |
| GemCis alone | Only if frail or refuses immunotherapy | Standard therapy but lower survival |
| PD-L1 testing | Not required | No impact on treatment selection |
Conclusion
[lab data]
2023-05-23 Anti-HBc Reactive
2023-05-23 Anti-HBc-Value 9.12 S/CO
2023-05-23 Anti-HCV Nonreactive
2023-05-23 Anti-HCV Value 0.16 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 3336.74 S/CO
2023-05-23 Anti-HBs 0.53 mIU/mL
[exam findings]
2025-10-09 CT - abdomen
2025-07-03 CT - abdomen
2025-04-21 ECG
2025-04-03 CT - abdomen
2024-12-27 CT - abdomen
2024-09-10 ECG
2024-09-10 CXR
2024-09-03 SONO - breast
2024-08-29 MRI - liver, spleen
2024-08-09 CT - abdomen
2024-04-03 CT - abdomen
2023-12-25 CT - abdomen
2023-09-07 CT - abdomen
2023-06-16 PET scan
2023-05-06 ECG
2023-05-06 CT - abdomen
[MedRec]
2025-10-31 SOAP Gastroenterology Zhan WeiYu
2025-10-23 ~ 2025-10-26 POMR Hemato-Oncology Gao WeiYao
2025-08-08, 2025-05-06, 2025-02-11, 2024-11-12, 2024-08-20, 2024-05-28, 2024-03-05, 2023-12-12, 2023-09-09, 2023-06-27 SOAP Gastroenterology Zhan WeiYu
2023-07-10 ~ 2023-07-13 POMR Hemato-Oncology Gao WeiYao
2023-05-06 ~ 2023-05-23 POMR Colorectal Surgery Chen ZhuangWei
[consultation]
2023-05-22 Hemato-Oncology
2023-05-08 Infectious Disease
[surgical operation]
2023-05-06
[immunochemotherapy]
Key insights / summary (as of 2025-11-07)
Problem 1. Metastatic colorectal cancer with progressive hepatic metastases on prolonged FOLFOX
Problem 2. Chemotherapy toxicity and oxaliplatin hypersensitivity/neuropathy risk
Problem 3. Chronic hepatitis B with high on-treatment oncologic risk
Problem 4. Hypertension and cardiovascular risk under fluoropyrimidine therapy
Problem 5. Hyperuricemia on treatment
Problem 6. Hematologic status under chemotherapy
Problem 7. Gastrointestinal and supportive care needs
Problem 8. Sleep disturbance/anxiety
Problem 9. Breast fibroadenoma surveillance
Active medication list observed (MAR 2025-11-06 → 2025-11-10 unless noted) - Decadron (dexamethasone) IV PRN - Benadryl (diphenhydramine) IV PRN - 0.9% Sodium Chloride IV BID - Apolin (hydralazine 25 mg) 1 tab PRN Q6H - Alpraline (alprazolam 0.5 mg) 1 tab HS PRN - Feburic (febuxostat 80 mg) 1 tab QD - Mosapin (mosapride citrate 5 mg) 1 tab TID - Pilian (cyproheptadine 4 mg) 1 tab TID - Sevikar (amlodipine/olmesartan 5/20 mg) 1 tab QD - Xyzal (levocetirizine 5 mg) 1 tab HS - Bao-gan (silymarin 150 mg) 1 cap TID - Vemlidy (tenofovir alafenamide 25 mg) 1 tab QD
Medication/treatment-related problems and recommendations (as of 2025-11-07)
[bedside visit]
Visit Date: 2025-04-01 Visit Time: 11:15 Subject: Suspected Oxaliplatin-related Adverse Drug Reaction (ADR) and Chemotherapy-Induced Nausea and Vomiting (CINV) Management
[labs confirm HBV: Vemlidy maintained, medication compliance assured]
Lab results (2023-05-23) showed HBsAg and anti-HBc reactive and Vemlidy (tenofovir alafenamide) is currently in use, no medication discrepany found.
[exam]
2025-10-17 CXR
2025-09-29 MRI - brain
2025-07-16 Tc-99m MDP Bone Scan
2025-07-14 PET
2025-05-14 MRI - brain
2025-05-05 PD-L1 (22C3)
2025-05-05 ROS1 IHC
2025-05-05 ROS1 IHC
2025-05-05 Tc-99m MDP bone scan with SPECT
2025-05-05 Lung Function Test
2025-05-02 PET
2025-04-29 Pathology - lung transbronchial biopsy
2025-04-28 CXR
[MedRec]
2025-10-13 ~ 2025-10-20 POMR Integrative Medicine Yang MuJun
2025-05-08 SOAP Metabolism and Endocrinology Liu FangQi
2025-04-28 ~ 2025-05-05 POMR Hemato-Oncology Lin YiTing
[medication]
Giotrif FC (afatinib 40mg) 1# QDAC
Giotrif FC (afatinib 30mg) 1# QDAC
Xgeva (denosumab 120mg) SC
Key insights / summary (2025-11-06)
Problem 1. Metastatic EGFR L858R lung adenocarcinoma with intracranial progression on afatinib
Problem 2. Hyperglycemia in type 2 diabetes with poor oral intake and parenteral nutrition
Problem 3. Recurrent urinary tract infection vs sterile pyuria/hematuria
Problem 4. Cancer-associated cachexia and malnutrition
Problem 5. Electrolyte and renal profile abnormalities
Problem 6. Bone metastases on denosumab with risk of hypocalcemia and osteonecrosis of the jaw
Problem 7. Hypertension and dyslipidemia under treatment
Problem 8. Coagulation and hematology status
Problem 9. Medication reconciliation and safety
Medications to consider (format: Brand Name (generic name)) - Tagrisso (osimertinib) 80 mg QD if EGFR T790M-positive after progression on afatinib. - Xgeva (denosumab) 120 mg SC every 4 weeks with calcium/vitamin D supplementation. - Lantus (insulin glargine U100) or Touejo (insulin glargine U300) for basal, and NovoRapid (insulin aspart) for prandial/correction while inpatient. - Megace ES (megestrol acetate) for appetite stimulation if benefits outweigh glycemic/thrombotic risks. - Zithromax (azithromycin) or other antibiotic per culture for UTI if indicated (final agent per susceptibility).
[exam finding]
2025-11-06 CXR
2025-05-28 ECG
2025-03-20 Pathology - bone marrow biopsy
2024-10-17 Pathology - bone marrow biopsy
2024-08-26 Pathology - bone marrow biopsy
2024-05-29 2D transthoracic echocardiography
2024-05-08 Pathology - bone marrow biopsy
[MedRec]
2025-10-09 ~ 2025-10-14 POMR Hemato-Oncology Gao WeiYao
2025-08-26 SOAP Hemato-Oncology Gao WeiYao
2024-07-28 ~ 2024-08-03 POMR Hemato-Oncology Gao WeiYao
2024-07-16 SOAP Hemato-Oncology Gao WeiYao
2024-07-12 SOAP Hemato-Oncology Gao WeiYao
2024-07-01 ~ 2024-07-06 POMR Hemato-Oncology Gao WeiYao
2024-06-18 SOAP Hemato-Oncology Gao WeiYao
2024-05-26 ~ 2024-06-05 POMR Hemato-Oncology Gao WeiYao
2024-05-07 ~ 2024-05-10 POMR Hemato-Oncology Gao WeiYao
[chemotherapy]
Venclexta (venetoclax 100mg) 1# QDCC
[note]
Venetoclax Adult Dosing - 2025-11-07 - https://www.uptodate.com/contents/venetoclax-drug-information
Key insights / summary (2025-11-07)
Problem 1. Acute myeloid leukemia (NPM1-mutated) on LDAC + Venclexta (venetoclax)
Problem 2. Anemia, grade 2 (multifactorial, therapy-related)
Problem 3. Thrombocytopenia, mild
Problem 4. Infection risk and current cough, improving
Problem 5. Chronic hepatitis B (anti-HBc positive) on prophylaxis
Problem 6. Cardiovascular comorbidity and treatment fitness
Problem 7. Renal function and CKD history
Problem 8. Medication reconciliation and drug–drug interactions
Problem 9. Electrolyte and metabolic profile
Disposition and follow-up
Potential Medication Issues
[MedRec]
2025-10-21 ~ 2025-11-01 POMR Cardiac Surgery Yang KaiWen
[Subjective]
[Objective]
[Assessment]
[Plan / Recommendation]
[lab data]
2025-10-29 INR 1.90
2025-10-14 INR 2.13
2025-08-12 INR 2.26
2025-05-15 INR 2.29
2025-02-17 INR 1.74
2024-11-28 INR 1.96
2024-09-11 INR 4.44
2024-06-19 INR 3.64
2024-03-27 INR 2.85
2024-01-03 INR 2.62
2023-12-25 INR 1.24
2023-12-15 INR 1.21
2020-09-09 INR 1.84
2020-06-10 INR 1.91
2020-05-13 INR 3.16
2020-05-04 INR 1.37
2020-04-29 INR 1.05
2020-04-27 INR 1.14
2020-04-25 INR 1.30
2020-04-23 INR 1.39
2020-04-22 INR 1.13
2020-04-21 INR 1.19
2020-04-20 INR 1.13
2020-04-08 INR 1.77
2020-04-07 INR 2.49
2020-02-26 INR 2.24
[MedRec]
2025-11-05, 2025-08-13, 2025-06-04, 2025-02-26, 2024-12-04, 2024-09-11 SOAP Cardiac Surgery Shen DaZhong
2025-11-04 SOAP Dentistry Su YingShan
2024-06-19, 2024-03-27, 2024-01-03 SOAP Cardiac Surgery Shen DaZhong
2023-12-15 ~ 2023-12-23 POMR Chest Medicine Lin QinJi
2020-09-09, 2020-06-10 SOAP Cardiac Surgery Shen DaZhong
2020-04-19 ~ 2020-04-29 POMR Cardiac Surgery Shen DaZhong
2020-04-07 ~ 2020-04-10 POMR Cardiology Xie JianAn
[Subjective]
[Objective]
[Assessment]
[Plan / Recommendation]
[exam finding]
2025-10-23 Bone densitometry - hip
2025-10-15 T-spine AP + Lat
2025-09-11 MRI - brain
2025-09-09 Sonography - abdomen
2025-09-08 Flow Volume Chart
2025-09-08 2D transthoracic echocardiography
2025-09-05 PET
2025-09-02 CT - chest
2025-09-02 Pathology - breast biopsy (no need margin)
[MedRec]
[immunochemotherapy]
2025-11-04 - paclitaxel 80mg/m2 100mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
2025-10-28 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min
2025-10-21 - paclitaxel 80mg/m2 100mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
2025-10-14 - paclitaxel 80mg/m2 100mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
2025-10-07 - Phesgo (pertuzumab 600mg, trastuzumab 600mg; 10mL) ST SC 5min + paclitaxel 80mg/m2 100mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
2025-09-30 - paclitaxel 80mg/m2 90mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
2025-09-23 - paclitaxel 80mg/m2 100mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
2025-09-16 - Phesgo (pertuzumab 1200mg, trastuzumab 600mg; 15mL) ST SC 8min + paclitaxel 80mg/m2 100mg NS 100mL 90min - betamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + pyridoxal (B6) 20mg + NS 250mL
[Subjective]
contact date 2025-10-29
[Objective]
oncologic regimen and dates
vitals and performance
laboratories (closest to diarrhea episode and admission)
disease background (for context)
[Assessment]
chemotherapy/anti-HER2-associated diarrhea, recurrent (likely CTCAE grade 2–3 by frequency)
hematologic toxicity and infection risk
dyspepsia/acid-related symptoms without overt mucositis
treatment course appropriateness
[Plan / Recommendation]
diarrhea management and prevention
chemotherapy adjustments and coordination
hematology and infection precautions
dyspepsia management
electrolyte and renal/hepatic surveillance
wound and symptom care (contextual)
patient education and coordination
medications referenced in this note (current or planned context)
follow-up and documentation
Problem 1. Metastatic HR+/HER2+ breast cancer on Phesgo + weekly paclitaxel
Problem 2. Chemotherapy-associated diarrhea and anorexia
Problem 3. Anemia, leukopenia with mild neutropenia, thrombocytosis
Problem 4. Suspected brain metastasis (5.5 mm right occipital lesion)
Problem 5. Bone metastases and back pain; prevention of skeletal-related events
Problem 6. Fungating chest wall/breast wound (ulceration 7×4 cm) with bleeding/odor risk
Problem 7. Cardiac safety under anti-HER2 therapy
Problem 8. Infection risk mitigation (neutropenia + ulcerated tumor)
Problem 9. Organ function and electrolytes monitoring during therapy
[exam finding]
2025-10-17 ECG
[MedRec]
2025-11-02 Admission Note
2025-10-28 SOAP Hemato-Oncology Gao WeiYao
[surgical operation]
2025-10-28
[chemotherapy]
FOLFOX
Key insights / summary
Problem 1. Metastatic gastric adenocarcinoma on palliative FOLFOX (C1D2)
Problem 2. Suspected 5-FU–associated cardiotoxicity (coronary vasospasm) in patient with CAD and prior stents
Problem 3. Normocytic anemia (likely cancer-related; CAD present)
Problem 4. Electrolyte and nutrition—hypocalcemia with low-normal magnesium; mild hypoalbuminemia
Problem 5. Blood pressure lability and cardiovascular secondary prevention during chemotherapy
Problem 6. Supportive care, symptoms, and medication safety in older adult
Problem 7. Venous access and thromboembolism/line care
Planned immediate actions (2025-11-04)
Current key medications (select)
Medication/treatment-related problems and recommendations
Follow-up plan (starting 2025-11-04)
[exam findings]
2025-10-08 CT - abdomen
2025-07-11 MRI - lower extremity
2025-06-06 Pathology - trichoepithelioma
2025-06-02 Papanicolaou test, Pap smear
2025-05-22 CT - abdomen
2025-05-16 Sonography - abdomen
2025-04-22 Femur Rt
2025-03-21 Tc-99m MDP bone scan
2025-01-16 CT
2024-12-18 Pathology - soft tissue tumor, extensive resection
2024-11-15 PET
2024-09-10 CT
2024-06-07 CT
2024-04-01 Sonography - abdomen
2024-03-15 Pathology - lymphnode biopsy
2024-02-06 PET
2022-08-19 Pathology - skin non-cyst/tag/debridement/plastic
2022-08-03 PET
2022-08-02 CT
[MedRec]
2025-10-31, 2025-08-08, 2025-05-16, 2025-02-21, 2024-12-06, 2024-09-13, 2024-06-21, 2024-03-29 SOAP Gastroenterology Chen HongDa
2024-04-22 ~ 2024-04-25 POMR Hemato-Oncology Gao WeiYao
2024-03-29 SOAP Gastroenterology Chen HongDa
2022-08-17 ~ 2022-08-26 POMR Plastic and Reconstructive Surgery
2022-07-29 ~ 2022-08-06 POMR Hemato-Oncology Gao WeiYao
[chemotherapy]
2025-06-20 - nivolumab 3mg/kg 180mg NS 100mL 90min
2025-06-06 - nivolumab 3mg/kg 180mg NS 100mL 90min
2025-05-20 - nivolumab 3mg/kg 180mg NS 100mL 90min
2025-05-06 - nivolumab 3mg/kg 180mg NS 100mL 90min
2025-04-22 - nivolumab 3mg/kg 180mg NS 100mL 90min
2025-04-08 - nivolumab 3mg/kg 180mg NS 100mL 90min
2024-11-22 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-10-24 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-09-17 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-08-23 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-07-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-07-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-06-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-05-20 - docetaxel 75mg/m2 120mg NS 250mL 1hr
2024-04-25 - docetaxel 75mg/m2 118mg NS 250mL 1hr
Key insights/summary
Problem 1. Metastatic melanoma progression after anti-PD-1 monotherapy
Problem 2. Suspected bone metastasis and fracture risk (right femoral intertrochanteric region)
Problem 3. HBV carrier under immunotherapy/chemotherapy
Problem 4. Electrolyte imbalances: recurrent hypokalemia with low-normal calcium
Problem 5. Hypoalbuminemia and cancer-related nutrition risk
Problem 6. Elevated LDH as a disease activity and prognostic marker
Problem 7. Adrenal metastasis and risk of adrenal insufficiency
Problem 8. Hematologic status and prior chemotherapy-related cytopenias (resolved)
Problem 9. Symptomatic and supportive care, including VTE vigilance
Problem 10. Left inguinal hernia with bowel content (incidental, recurrent)
Additional immediate next steps (prioritized actionable list)
[exam finding]
2025-10-08 2D transthoracic echocardiography
2025-06-03 CT
2025-06-03 Sonography - abdomen
2025-04-16 2D transthoracic echocardiography
2025-03-28 Pathology - breast mastectomy with regional lymph nodes
2025-03-19 MRI - breast
2025-02-26 2D transthoracic echocardiography
2024-10-29 2D transthoracic echocardiography
2024-10-25 15:48 Pathology - lymphnode biopsy
2024-10-25 15:47 Pathology - breast biopsy (no need margin)
2024-10-24 CT - chest
2024-10-22 PET
2024-10-22 Nerve Conduction Velocity, NCV
2024-10-15 Papanicolaou test, Pap smear
2024-10-14 Sonography - gynecology
2024-07-15 Sonography - thyroid
2023-11-14 Papanicolaou test, Pap smear
2023-11-13 Sonography - gynecology
2021-09-20 Pathology breast mastectomy with regional lymph nodes
2021-09-15 The Tc-99m MDP bone scan
2021-09-10 Bone densitometry - spine
2021-09-03 Pathology - breast biopsy (no need margin)
[MedRec]
2024-10-29 ~ 2025-10-30 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-10-08 ~ 2025-10-09 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-10-08 SOAP Rheumatology and Immunology Chen ZhengHong
2024-11-20 ~ 2024-11-21 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-11-06 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-10-21 ~ 2024-10-30 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-10-14, 2024-07-022, 2024-04-29, 2024-02-05, 2023-11-13, 2023-08-21, 2023-05-29, 2023-03-06, 2022-12-12, 2022-09-19, 2022-06-29, 2022-04-06, 2022-01-12, 2021-10-20, 2021-09-27 SOAP General and Gastroenterological Surgery Zhang YaoRen
2021-09-16 ~ 2021-09-18 POMR General and Gastroenterological Surgery Zhang YaoRen
[surgical operation]
2025-03-28
2024-10-29
2021-09-17
[radiotherapy]
2021-10-22 ~ 2021-12-02 - 5000cGy/25 fractions (6 MV photon) to Rt breast, 1000cGy/5 fractions (6 MeV electron) to scar
[immunochemotherapy]
2025-10-29 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 200mg NS 250mL 90min (TDM1)
2025-10-08 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 227mg NS 250mL 90min (TDM1)
2025-09-17 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 230mg NS 250mL 90min (TDM1)
2025-08-27 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 230mg NS 250mL 90min (TDM1)
2025-08-06 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 200mg NS 250mL 90min (TDM1)
2025-07-14 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 185mg NS 250mL 90min (TDM1)
2025-06-18 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 230mg NS 250mL 90min (TDM1)
2025-05-28 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 230mg NS 250mL 90min (TDM1)
2025-05-07 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 234mg NS 250mL 90min (TDM1)
2025-04-16 - Kadcyla (ado-trastuzumab emtansine) 3.6mg/kg 238mg NS 250mL 90min (TDM1)
2025-03-27 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
2025-02-26 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 126mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr
2025-02-03 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 126mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr
2025-01-10 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 125mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr
2024-12-20 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr
2024-11-20 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr
2024-10-30 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr
2024-10-28 - rituximab 500mg/m2 500mg NS 500mL 12hr
2025-10-08 ~ 2025-11-13 ongoing - Nerlynx (neratinib 40mg) 6# QDCC
2021-09-27 ~ 2024-11-11 - Nolvadex (tamoxifen citrate 10mg) 1# BID
[note]
Neratinib Dosing Adult - 2025-11-03 - https://www.uptodate.com/contents/neratinib-drug-information
Note: If not utilizing neratinib dose escalation, administer antidiarrheal prophylaxis during the first 56 days of therapy; initiate with the first neratinib dose (see “Premedications”).
Breast cancer, HER2 positive, advanced or metastatic
Breast cancer, HER2 positive, early stage, extended adjuvant therapy
Ado-trastuzumab emtansine Dosing Adult - 2025-11-03 - https://www.uptodate.com/contents/ado-trastuzumab-emtansine-drug-information
PLT AST
[Subjective]
Telephone follow-up by pharmacist on 2025-11-03
[Objective]
Hematology and chemistry (selected)
Breast cancer treatment timeline
Concurrent/PRN meds noted in chart (selected)
HBV risk context
[Assessment]
Thrombocytopenia with mucosal bleeding symptoms on Kadcyla
Nerlynx initiation risk-benefit
Transaminase surveillance
Patient/caregiver education and safety gaps
[Plan / Recommendation]
Thrombocytopenia and epistaxis
Nerlynx strategy
Liver monitoring
HBV verification and prevention
Macrocytosis workup and supportive care
Care coordination and follow-up
Key insights/summary
Problem 1. HER2-positive right breast cancer, s/p neoadjuvant TCHP and MRM, now on adjuvant T-DM1 with nonstandard neratinib overlap
Problem 2. Grade 3 thrombocytopenia, likely T-DM1–related
Problem 3. Dermatomyositis (paraneoplastic; anti-TIF1γ+++, anti-PL-12+), risk of ILD
Problem 4. Cardiac function while on HER2-targeted therapy
Problem 5. HBV core antibody positive history with prior rituximab exposure
Problem 6. Macrocytosis with mild anemia
Problem 7. Pulmonary 5 mm LUL ground-glass nodule, stable
Problem 8. Hepatic and renal function on T-DM1/neratinib
Problem 9. Uterine fibroids and gynecologic considerations
Problem 10. Thyroid nodules with autoimmune thyroid disease
Problem 11. Right median neuropathy
Problem 12. Gastrointestinal mucosal disease
Problem 13. Splenic cyst
Problem 14. Supportive care, rehab, and vaccinations
Medications noted - Kadcyla (ado-trastuzumab emtansine) ongoing through 2025-10-29; currently to be held. - Nerlynx (neratinib) 40 mg, 6 tablets daily planned 2025-10-08 to 2025-11-13 — recommend discontinuation now; reconsider only post–T-DM1 and typically for HR+ disease. - Plaquenil (hydroxychloroquine) 200 mg QDCC; Compesolon (prednisolone) low-dose; Allegra (fexofenadine), Xyzal (levocetirizine), Ulstop F.C. (famotidine), loperamide PRN; prior Fulphila (pegfilgrastim) with neoadjuvant chemotherapy.
Follow-up plan summary
Differential diagnosis based on lab results only (not used; incomplete info)
[exam finding] (not completed)
2025-10-31 MRI - thigh
2025-10-30 Laryngoscopy
2025-05-19 Pathology - oral cancer (wide excision + lymph node)
2025-02-17 Pathology
2025-02-17 Pathology
[MedRec]
2025-05-14 ~ 2025-06-04 POMR Ear Nose Throat Huang TongCun
2025-02-14 ~ 2025-03-06 POMR Hemato-Oncology Xia HeXiong
[chemotherapy]
[Const-K Extended Release (KCl) Tablets 750mg/10mEq/tab - tube feeding]
As there are no other oral potassium supplements available in this hospital, dissolve the Const-K in warm water for administration via tube feeding. Continue to closely monitor the patient’s serum potassium level and renal function.
Key Insights / Summary
Problem 1. Suspected metastatic progression (right thigh mass and left gluteal lesion) with severe right-thigh pain
Problem 2. Hypercalcemia of malignancy with mixed electrolyte disorders and hyperuricemia
Problem 3. Cancer-related pain, inadequately controlled
Problem 4. Right-thigh swelling and VTE risk
Problem 5. Anemia and thrombocytopenia
Problem 6. Antimicrobial stewardship
Problem 7. Electrolyte and renal-hepatic function management
Problem 8. Nutrition and functional status
Problem 9. HBV exposure/prophylaxis in the context of cytotoxic therapy
Problem 10. Goals of care and systemic therapy planning
Problem 11. Sleep/anxiety and polypharmacy safety
Follow-up and Monitoring Plan (next 72 h)
[exam finding]
2025-10-02 Pathology - colorectal polyp
2025-10-02 2D transthoracic echocardiography
2025-10-01 Miniprobe Endoscopic Ultrasound
2025-09-18 CT - abdomen
2025-09-05 Pathology - colon biopsy
2025-09-04 Colonoscopy
2025-08-25 PET
2025-08-12 Pathology - breast biopsy (no need margin)
2025-06-23 Sonography - breast
[MedRec]
2025-10-24 SOAP Hemato-Oncology Yang MuJun
2025-10-17 SOAP Hemato-Oncology Yang MuJun
2025-10-08 ~ 2025-10-10 POMR Hemato-Oncology Yang MuJun
[chemotherapy]
2025-10-31 - pembrolizumab 200mg NS 200mL 0.5hr + paclitaxel 80mg/m2 110mg NS 250mL 1.5hr + carboplatin AUC 5 500mg NS 250mL 2hr (C2D1) - dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + Akynzeo (netupitant 300mg + palonosetron 0.5mg) 1# PO + NS 250mL
2025-10-24 - paclitaxel 80mg/m2 110mg NS 250mL 1.5hr + B-Complex (B1, B2, B6, niacinamide, dexpanthenol) NS 500mL 1hr (C1D15) - dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + Akynzeo (netupitant 300mg + palonosetron 0.5mg) 1# PO + NS 250mL 2025-10-17 - paclitaxel 80mg/m2 110mg NS 250mL 1.5hr + B-Complex (B1, B2, B6, niacinamide, dexpanthenol) NS 500mL 1hr (C1D8) - dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + Akynzeo (netupitant 300mg + palonosetron 0.5mg) 1# PO + NS 250mL 2025-10-09 - pembrolizumab 200mg NS 200mL 0.5hr + paclitaxel 80mg/m2 110mg NS 250mL 1.5hr + carboplatin AUC 5 500mg NS 250mL 2hr (C1D1) - dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + Akynzeo (netupitant 300mg + palonosetron 0.5mg) 1# PO + NS 250mL
Key Insights/Summary
Problem 1. Triple-negative breast cancer on neoadjuvant pembrolizumab + paclitaxel/carboplatin
Problem 2. Chemotherapy-related cytopenias (anemia, evolving thrombocytopenia; prior leukopenia resolved)
Problem 3. Peripheral neuropathy likely paclitaxel-induced
Problem 4. HBV carrier on antiviral prophylaxis during chemo-IO
Problem 5. Immune-related adverse event surveillance (endocrine, hepatic, pulmonary, dermatologic)
Problem 6. Renal function and hydration while receiving carboplatin
Problem 7. Electrolyte and nutritional support; GI prophylaxis
Problem 8. Central venous Port-A care and infection prevention
Problem 9. Cecal mass under evaluation (pathology favors myoma; earlier EUS suggested GIST)
Problem 10. Constipation risk and supportive medications
Medication Review
[exam finding]
2025-10-30 T-L-spine AP + Lat
2025-10-29 ECG
2025-10-22 MRI - brain
2025-10-20 Sonography - abdomen
2025-10-15 ECG
2025-09-26 CT - abdomen
2025-09-18 Sonography - abdomen
2025-07-26 CT - abdomen
[MedRec]
2025-10-15 ~ 2025-10-24 POMR Hemato-Oncology He JingLiang
2023-03-21 ~ 2023-04-02 POMR Obstetrics and Gynecology Huang SiCheng
2022-12-24 ~ 2022-12-30 POMR Obstetrics and Gynecology Huang SiCheng
[surgical operation]
[radiotherapy]
[immunochemotherapy]
2025-10-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min - dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
2025-07-28 - liposome doxorubicin 30mg/m2 45mg D5W 250mL 1hr + carboplatin AUC 4 385mg NS 250mL 2hr
2025-05-29 - liposome doxorubicin 30mg/m2 45mg D5W 250mL 1hr + carboplatin AUC 4 385mg NS 250mL 2hr
2025-04-30 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 420mg NS 250mL 2hr
2025-04-07 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 440mg NS 250mL 2hr
2025-03-14 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 380mg NS 250mL 2hr
2025-02-13 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 5 540mg NS 250mL 2hr
2025-01-14 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 5 550mg NS 250mL 2hr
2024-06-21 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-05-30 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-04-29 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-04-09 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-03-13 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-02-19 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-01-30 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-01-03 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-12-14 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-11-13 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-10-20 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-09-28 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-09-04 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-07-24 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2023-07-04 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
2023-06-13 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 510mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)
2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr
2025-04-29 ~ - Lynparza (olaparib 150mg) HS (IPD)
2025-04-07 ~ - Lynparza (olaparib 150mg) HS (IPD)
2025-02-13 ~ - Lynparza (olaparib 150mg) BIDCC (IPD)
2025-04-16 - Xgeva (denosumab 120mg) SC (OPD)
2025-03-14 - Xgeva (denosumab 120mg) SC (IPD)
2025-02-13 - Xgeva (denosumab 120mg) SC (IPD)
2025-01-07 - Xgeva (denosumab 120mg) SC (OPD)
2025-04-07 - PG2 Lyo Injection (polysaccharides of Astragalus membranaceus 500mg) IVD (IPD)
2025-03-15 - PG2 Lyo Injection (polysaccharides of Astragalus membranaceus 500mg) IVD (IPD)
2023-01-06 ~ undergoing (as of 2025-10-31) - Vemlidy (tenofovir alafenamide 25mg) 1# QD (OPD)
Key Insights/Summary
Problem 1. Pancytopenia with severe thrombocytopenia
Problem 2. Hepatic dysfunction
Problem 3. Electrolyte disturbances (Hyponatremia, Hypocalcemia, Hyperkalemia)
Problem 4. Disease progression with suspected bone marrow metastases
Problem 5. Low blood pressure and cardiovascular instability
Problem 6. End-stage ovarian cancer with prior immunotherapy
Problem 7. Pain and opioid management
Problem 8. Risk of bleeding and fall
Medication Review
Summary
Problem 1. Hematologic abnormalities (anemia, thrombocytopenia)
Problem 2. Urinary tract infection
Problem 3. Electrolyte imbalance (hypocalcemia, hypokalemia, hypomagnesemia)
Problem 4. Advanced ovarian cancer with metastatic disease
The patient is a 65-year-old woman with bilateral grade 3 ovarian
endometrioid carcinoma, initially staged as FIGO IIIC (ypT3cN1b)
following HIPEC and debulking on 2023-03-22, with subsequent progression
to stage IV due to confirmed liver, lung, bone, adrenal, and lymph node
metastases (PET 2024-12-24, MRI 2025-01-15). She received multiple lines
of chemotherapy (Taxol/Carboplatin → Bevacizumab → Lipodox/Carboplatin),
and is currently under maintenance therapy with Lynparza (olaparib) and
supportive bone metastasis management with Xgeva (denosumab).
CA-125 shows persistent biochemical control, while CA-199 demonstrates a
non-linear but generally declining trend. Latest ECOG PS is 1,
indicating preserved function. However, the patient is developing
chemotherapy-induced hematologic toxicity (anemia and thrombocytopenia),
and hypomagnesemia persists. There is no clinical evidence of active
infection, organ failure, or neurologic deterioration.
Problem 1. Metastatic ovarian endometrioid carcinoma (stage IV)
Problem 2. Chemotherapy-induced anemia and thrombocytopenia
Problem 3. Hypomagnesemia
Problem 4. Chronic viral hepatitis B (resolved/controlled carrier)
Problem 5. Cancer-related fatigue and insomnia
[assessment]
[exam finding]
2025-10-29 CXR
2025-10-29 Abdomen - standing (diaphragm)
2025-10-23, 2025-10-18 Abdomen - Standing (Diaphragm)
2025-10-20 CXR
2025-10-20, 2025-10-17 Abdomen - Standing KUB
2025-10-16, 2025-09-24 Abdomen - Standing (Diaphragm)
2025-10-15 CT - abdomen
2025-08-29 IVP
2025-08-27 Sonography - abdomen
2025-08-24 ECG
2025-08-18 CT - abdomen
2025-08-07 CXR
[MedRec]
2025-10-17 MultiTeam - Social Work
Consultation Date: 2025-10-15
Reason for Consultation: Emotional distress experienced by
patient and family during hospitalization
Status: Case closed after a single intervention
2025-10-17 09:52 – Social Worker: Jiang PinXuan
2025-10-17 08:56 – Social Worker: Jiang PinXuan
2025-10-16 MultiTeam - Psycho-oncology
2025-10-12 ~ 2025-10-24 POMR Hemato-Oncology Gao WeiYao
2025-08-26 MultiTeam - Cancer Case Manager
2025-08-24 ~ 2025-09-01 POMR Hemato-Oncology Gao WeiYao
[chemotherapy]
2025-10-30 - Irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 520mg NS 250mL 2hr + fluorouracil 2800mg/m2 3650mg NS 500mL 46hr - dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
2025-10-13 - Irinotecan 180mg/m2 239mg D5W 90min + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3729mg NS 500mL 46hr - dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
2025-09-25 - Irinotecan 180mg/m2 240mg D5W 90min + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3738mg NS 500mL 46hr - dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
2025-08-30 - Irinotecan 180mg/m2 250mg D5W 90min + leucovorin 400mg/m2 555mg NS 250mL 2hr + fluorouracil 2800mg/m2 3890mg NS 500mL 46hr - dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
Key insights / summary
Problem 1. Metastatic sigmoid colon adenocarcinoma on FOLFIRI (current cycle C2D15)
Problem 2. Recent suspected GI perforation and current bowel risk (ileus/constipation)
Problem 3. Infection/sepsis risk, currently improved but inflammatory markers elevated
Problem 4. Hematologic status: anemia of chronic disease/chemotherapy; reactive thrombocytosis; prior severe neutropenia
Problem 5. Electrolyte and fluid balance: hyponatremia, prior hypokalemia/hypomagnesemia, hydration during chemo
Problem 6. Nutritional risk and cachexia
Problem 7. Chronic hepatitis B exposure with reactivation risk under chemotherapy
Problem 8. VTE risk with markedly elevated D-dimer
Problem 9. Right hydronephrosis/hydroureter from pelvic mass effect
Problem 10. T12 compression fracture and pain control
Problem 11. Symptom control and supportive medications during this admission
Medication/treatment safety priorities (2025-10-31)
[exam finding]
2025-10-22 2D transthoracic echocardiography
2025-40-20 12:40 CXR
2025-10-20 Pathology - bone marrow biopsy
[chemotherapy]
2025-10-31 - daunorubicin 45mg/m2 45mg NS 100mL 10min D1-2 + cytarabine 100mg/m2 100mg NS 500mL 24hr D1-5 (dose 70%) - dephenhydramine 30mg + famotidine 20mg + metoclipramide 10mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
[bedside visit - patient education for chemotherapy]
2025-10-31 11:15: Visited the patient in the ward.
At the time, another person was accompanying the patient at the bedside (a caregiver?), and the patient’s mental status was good. The premedication had already been started, but the chemotherapy had not yet been administered.
I explained to the patient the function and possible adverse effects of “daunorubicin + cytarabine”, and stressed the importance of infection prevention following treatment.
It was incidentally learned that the patient was privately taking an iron supplement on their own. Given that the patient’s Ferritin level was elevated, I verbally advised them at that time that they do not need to continue taking the supplement.
The patient stated she understood and would comply.
Key insights / summary
Problem 1. Acute myeloid leukemia, not having achieved remission
Problem 2. Pancytopenia with symptomatic severe anemia and thrombocytopenia
Problem 3. High risk of febrile neutropenia and invasive infection
Problem 4. Tumor lysis syndrome (TLS) risk during induction
Problem 5. Electrolyte disorder: persistent hypokalemia with mild hyponatremia
Problem 6. Cardiac strain risk in the setting of anemia and anthracycline exposure
Problem 7. Transfusion-related iron overload
Problem 8. Cancer-associated coagulation activation without overt DIC
Problem 9. Hypertension and medication management during induction
Problem 10. Autoimmune diseases (rheumatoid arthritis, Sjogren) with held immunosuppression
Medication reconciliation snapshot (active around 2025-10-31)
Disposition and monitoring checklist
ChatGPT 5 differential diagnosis based only on labs
ChatGPT 5 differential diagnosis based only on available info
[lab data]
2023-08-10 Anti-β2-glycoprotein-I Ab 0.6 U/mL
2023-08-10 Anti-cardiolopin IgG 0.7 GPL-U/mL
2023-08-10 Anti-cardiolipin IgM 1.3 MPL-U/mL
2023-08-08 CEA (NM) 89.031 ng/ml
2023-08-07 HBsAg Nonreactive
2023-08-07 HBsAg (Value) 0.36 S/CO
2023-08-07 Anti-HBc Reactive
2023-08-07 Anti-HBc-Value 6.47 S/CO
2023-08-07 Anti-HCV Nonreactive
2023-08-07 Anti-HCV Value 0.09 S/CO
2023-08-07 CEA 96.78 ng/mL
2023-08-07 CA199 29.24 U/mL
2023-08-07 D-dimer > 10000.00 ng/mL(FEU)
2023-08-07 PT 11.1 sec
2023-08-07 INR 1.08
2023-08-07 APTT 25.7 sec
2023-08-07 Fibrinogen(quantita) 364.4 mg/dL
2023-08-04 Alkaline phosphatase 931 U/L
[exam findings]
2025-10-29 CXR
2025-10-12 CXR
2025-10-10 CT
2025-10-03 CT
2025-08-19 T-L-spine AP + Lat.
2025-07-22 Sonography - abdomen
2025-06-28 CT - chest
2025-05-27, 2025-04-28 CXR
2025-04-15 Tc-99m MDP bone scan
2025-03-11 CT - chest
2025-01-21 Sonography - abdomen
2024-12-31 CXR
2024-11-10 KUB
[MedRec]
2025-10-10 ~ 2025-10-14 POMR Cardiology Lin ShuangJin
2024-10-19 ~ 2024-10-31 POMR Hemato-Oncology Gao WeiYao
2023-08-04 ~ 2023-08-21 POMR Hemato-Oncology Gao WeiYao
2023-08-04 SOAP Hemato-Oncology Gao WeiYao
[chemotherapy]
2025-05-06 ~ 2025-11-04 ongoing - Giotrif (afatinib 30mg) 1# QDAC
2025-03-18 - pemetrexed 500mg/m2 780mg NS 100mL 10min + carboplatin AUC 5 430mg NS 250mL 2hr - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
2025-02-26 - pemetrexed 500mg/m2 780mg NS 100mL 10min + carboplatin AUC 5 430mg NS 250mL 2hr - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
2025-02-04- pemetrexed 500mg/m2 780mg NS 100mL 10min + carboplatin AUC 5 430mg NS 250mL 2hr - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
2025-01-14- pemetrexed 500mg/m2 780mg NS 100mL 10min + carboplatin AUC 5 430mg NS 250mL 2hr - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
2024-12-03 - pemetrexed 500mg/m2 780mg NS 100mL 10min + carboplatin AUC 5 430mg NS 250mL 2hr - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
2023-08-17 - pemetrexed 500mg/m2 800mg NS 100mL 10min + NS 500mL (before CDDP) + cisplatin 75mg/m2 120mg NS 350mL 3hr + NS 500mL (after CDDP) - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
2023-09-01 ~ 2023-12-08 - Iressa (gefitinib 250mg) 1# QD
[Teicoplanin and Meropenem - Dosing Strategy]
Note: Use actual body weight (43.3 kg) for all calculations.
Loading Dose (Days 1–3)
Maintenance Dose (Starting Day 4)
Therapeutic Drug Monitoring (TDM)
Adjustment for CrCl 26–50 mL/min.
Recommended Regimen
Key insights/summary (2025-10-30)
Problem 1. Biochemical progression of metastatic malignancy
Problem 2. Cancer-associated thrombosis with extreme D-dimer and prior PE/DVT
Problem 3. Chronic kidney disease with prior AKI; current eGFR ~43
Problem 4. Chronic anemia with intermittent thrombocytosis
Problem 5. History of significant hypercalcemia with current normocalcemia
Problem 6. Dyslipidemia and cardiometabolic risk in oncology patient with diabetes
Problem 7. HBV core Ab positive with prophylaxis counseling
Problem 8. Recent urinary tract infection pattern, currently resolved
Problem 9. Electrolyte and acid–base considerations
Medication and safety checklist (2025-10-30)
Planned tests/orders today (2025-10-30)
Medication/treatment-related safety overview (2025-10-30)
High-priority problems and actions
Immediate orders and follow-up checkpoints (2025-10-30)
Clinical Summary
Recommendations:
Prognostic Considerations:
[Context of Switching to Pemetrexed + Carboplatin]
Implications of Switching
Next Steps
[exam findings]
[MedRec]
2025-08-26 ~ 2025-09-15 POMR Hemato-Oncology Xia HeXiong
[consultation]
[surgical operation]
2024-07-03
2023-11-09
2021-01-17 15:53
2020-03-18 13:10
2017-03-13 20:11
[chemotherapy]
2025-10-29
2025-10-03
2025-09-12
2025-06-27
2025-06-04
2025-05-16
2025-04-28
2025-04-02
2025-03-12
2025-02-14
2025-01-17
2024-12-19
2024-11-21
2024-10-29
2024-10-04
2024-09-11
2024-08-26
2024-08-07
2024-07-17
Key Insight / Summary
Problem 1. Chronic Kidney Disease on Hemodialysis
Problem 2. Anemia and ESA Use
Problem 3. Hepatic Lesion – Suspicious for Metastasis
Problem 4. Small Bowel Obstruction – Adhesive or Tumor-Related
Problem 5. Gallbladder and Biliary Abnormalities
Problem 6. Cardiopulmonary Issues
Problem 7. Gastrointestinal Abnormalities (Polyps, Esophagitis, Suspected Gastric Subepithelial Lesion)
Problem 8. Pain and Orthopedic Degeneration
Medication and Treatment-Related Problems and Recommendations:
The patient is a chronic hemodialysis-dependent individual with metastatic colorectal cancer (liver metastases, recurrent progression), receiving modified FOLFIRI chemotherapy. As of 2025-06-27, the patient remains functionally stable under integrated care, including nephrology and palliative co-management. The key concerns include:
Problem 1. Hypertension and Cardiovascular Stress under Hemodialysis
Problem 2. Anemia under ESA + Hemodialysis
Problem 3. Chemotherapy Tolerability and Mucositis
Problem 4. Immunosuppression in ESRD with Prior Autoimmune History (not posted)
Problem 5. Palliative Integration and Advance Care Planning (not posted)
This 66-year-old woman with a history of systemic lupus erythematosus (SLE), end-stage renal disease (ESRD) on hemodialysis QW135, heart failure with atrial fibrillation, and chronic hepatitis B is undergoing palliative FOLFIRI chemotherapy for sigmoid colon adenocarcinoma (pT1N0M0, G2, Stage I) with liver metastases (Stage IVa). Since chemotherapy initiation on 2024-07-17, she has remained free from acute gastrointestinal toxicities or febrile neutropenia. However, she has developed progressive anemia and thrombocytopenia, worsening renal function, and new cardiovascular findings.
On 2025-04-01, she received epoetin beta following a hemoglobin level of 7.1 g/dL, in line with nephrology recommendations for ESA initiation when Hgb <11 g/dL. Echocardiography on 2025-03-06 confirmed moderate aortic stenosis and mild pulmonary hypertension. Although autoimmune hemolysis is not definitively diagnosed, the presence of a positive direct Coombs test (2025-03-11), systemic lupus erythematosus history, and persistent normocytic anemia despite transfusions raise clinical suspicion.
Problem 1. ESRD on Hemodialysis
Problem 2. Progressive Anemia and Suspected Autoimmune Hemolysis
Problem 3. Neutropenia and Chemotherapy-Related Marrow Suppression
Problem 4. Colon Cancer with Liver Metastasis under Palliative FOLFIRI
Problem 5. SLE with Multisystem Involvement (LN, AIHA)
Problem 6. Cardiovascular Disease: HFpEF, Aortic Stenosis, AFib
Problem 7. Thyroid Dysfunction - Suspected Subclinical Hypothyroidism
Since the last review on 2025-01-17, notable changes in the patient’s condition include:
Problem 1: Anemia (Worsening)
Problem 2: Renal Function (Improved with Dialysis)
Problem 3: Hypertension and Bradycardia
Problem 4: Liver Metastases (Stable on FOLFIRI)
Problem 5: Chronic Hepatitis B (Stable on Vemlidy)
[Summary]
The patient is a 66-year-old woman with a history of adenocarcinoma of the sigmoid colon (stage IVa due to liver metastases) who has been receiving palliative chemotherapy with FOLFIRI since 2024-07-17.
She also has end-stage renal disease (ESRD) under hemodialysis three times weekly (QW135), heart failure, atrial fibrillation, systemic lupus erythematosus (SLE), and chronic hepatitis B.
Her condition is currently stable, with planned chemotherapy (C5D1) starting on 2025-01-17.
Notable ongoing issues include anemia, hypertension, and renal dysfunction.
Vital signs are stable, with mild hypertension (highest 178/78 mmHg on 2025-01-15).
[Problems]
Problem 1. Anemia
Problem 2. End-Stage Renal Disease (ESRD)
Problem 3. Hypertension
Problem 4. Liver Metastases (Adenocarcinoma of S-Colon)
Problem 5. Chronic Hepatitis B
[persistent anemia in ESRD patient post-neutropenia recovery]
Granocyte (lenograstim) has been prescribed, and the updated lab results show no more neutropenia.
However, anemia persists, likely due to the patient’s end-stage renal disease (ESRD). The records indicate a blood transfusion on 2024-10-02. If the anemia is indeed caused by renal insufficiency, the use of erythropoiesis-stimulating agents (ESAs) could be considered as a treatment option.
2024-10-03 WBC 8.04 x10^3/uL
2024-10-01 WBC 1.92 x10^3/uL
2024-09-24 WBC 3.21 x10^3/uL
2024-10-03 Neutrophil 82.5 %
2024-10-01 Neutrophil 69.8 %
2024-09-24 Neutrophil 75.7 %
2024-10-03 HGB 8.7 g/dL
2024-10-01 HGB 7.6 g/dL
2024-09-24 HGB 9.1 g/dL
[Considerations for Irinotecan Dosing and Timing with Hemodialysis]
Irinotecan, a prodrug, is hydrolyzed into the active metabolite SN-38, which is further metabolized into the inactive glucuronide conjugate SN-38G. While the primary elimination route is biliary, approximately 32% of the dose is excreted via urine (~22% as unchanged drug, ~3% as SN-38G, and <1% as SN-38). SN-38 is highly protein-bound (~99%), primarily to albumin. Ref: https://doi.org/10.1200/JCO.2022.40.16_suppl.e1351
Considering that liver function results on 2024-08-25 were normal and the patient is currently undergoing hemodialysis, administering irinotecan 1 hour before dialysis might result in the drug being partially dialyzed before it fully converts to SN-38, potentially reducing the actual effective dose of SN-38. Currently, the FOLFIRI regimen has already reduced irinotecan from 180 mg/m² to 120 mg/m². Please consider the possibility of unintentional underdosing of irinotecan.
[managing FOLFIRI regimen in HD patients]
Systemic treatment has not yet been initiated, and tumor markers continue to show a rising trend.
The planned FOLFIRI regimen includes fluorouracil, which is used for the patient on intermittent hemodialysis (thrice weekly). Fluorouracil itself is not significantly dialyzable; however, its metabolite FBAL may be substantially removed by dialysis (extraction ratio 0.73 to 0.84). No dosage adjustment is necessary for fluorouracil. When the scheduled dose falls on a hemodialysis day, it should be administered after hemodialysis. Patients must be monitored closely for the potential development of hyperammonemic encephalopathy associated with FBAL accumulation in those with end-stage kidney disease. Removing FBAL by hemodialysis can be effective in preventing or treating hyperammonemia.
However, the use of irinotecan in the patient on intermittent hemodialysis poses risks. Irinotecan may be partially dialyzable, but its active metabolite, SN38, is not. The manufacturer does not recommend its use due to the higher risk of toxicity in patients with end-stage kidney disease (ESKD). Initially, if benefits outweigh the risks, it may be started at 50% to 66% of the usual recommended dose. Given the variability in patient responses, when the usual indication-specific dose is 100 to 150 mg/m2 once weekly, it may be safest to start at 50 mg/m2 once weekly. Doses may be cautiously increased if tolerated; however, severe toxicity at 80 mg/m2 weekly (grade 4 neutropenia and death in a patient with UGT1A polymorphism) and 100 mg/m2 weekly (grade 4 diarrhea) has been reported. Irinotecan should be administered after hemodialysis or on non-dialysis days.
Currently, the patient’s multiple liver metastases have not affected AST, ALT, or bilirubin readings, and there is no need to adjust the FOLFIRI dosage for liver function at this time.
[exam findings]
[MedRec]
2025-10-17 ~ 2025-10-21 POMR Hemato-Oncology Xia HeXiong
Discharge Diagnoses - High grade serous carcinoma of the ovary with peritoneal carcinomatosis, FIGO IIIC; s/p neoadjuvant Paclitaxel + Carboplatin (C6, 2024-04 to 2024-10), debulking surgery with HIPEC on 2024-07-26; recurrence s/p exploratory laparotomy and tumor excision on 2025-05-05; on Paclitaxel 175 mg/m2 + Carboplatin AUC 5 Q3W since 2025-06-07; current admission for Bevacizumab + TC - Essential hypertension - Resolved hepatitis B, Anti-HBc reactive
Chief Complaint - For chemotherapy
History of Present Illness - 67-year-old woman with hypertension and hyperlipidemia; obstetric history G2P1SA1, menopause at 48 - Initial presentation in early 2024 with intermittent dull lower abdominal pain and incomplete defecation; ultrasound and CT suggested ovarian carcinoma with carcinomatosis; CA-125 elevated to 2,333.3 U/mL; laparoscopic biopsy on 2024-03-29 showed high-grade serous carcinoma, ovary origin (CK7+, WT-1+, p53 aberrant) - Received neoadjuvant Paclitaxel/Carboplatin (2024-04-19 to 2024-10-18), then debulking surgery with HIPEC on 2024-07-26 - Rising CA-125 to 86.4 U/mL on 2025-04-12 and MRI on 2025-04-10 showed 0.8 cm pelvic nodule; exploratory laparotomy on 2025-05-05 found multifocal peritoneal seeding; pathology confirmed high-grade serous carcinoma; intra-op small bowel perforation repaired - Systemic therapy since 2025-06-06: Bevacizumab + Paclitaxel/Carboplatin cycles on 2025-06-06, 2025-07-10, 2025-08-14, 2025-09-26; CT on 2025-06-06 noted peritoneal disease - Current admission for Bevacizumab (#5) + C11 TC on 2025-10-17
Hospital Course - On admission, performance status 1 with stable vitals; baseline labs on 2025-10-17 showed adequate marrow, renal, and hepatic function for treatment - Pre-chemotherapy hydration and Limeson administered per protocol - Chemotherapy with Bevacizumab/Taxol/Carboplatin given on 2025-10-18 without immediate complications - Planned post-chemotherapy prophylaxis with lenograstim 250 mcg SC daily for 3 days (2025-10-27 to 2025-10-29) arranged for home administration - Discharged on 2025-10-21 in stable condition with outpatient follow-up arranged
Discharge Prescription - Granocyte (lenograstim) 250 mcg/vial, 1 vial QD, SC, total 3 vials, remarks: administer on 2025-10-27 to 2025-10-29 - Anxiedin (lorazepam) 0.5 mg/tab, 1 tab HS, PO, 14 days, total 14 tabs
2025-09-26 ~ 2025-09-30 POMR Hemato-Oncology Xia HeXiong
2025-05-01 ~ 2025-05-20 POMR Hemato-Oncology Xia HeXiong
2024-07-13 ~ 2024-07-25 POMR Obstetrics and Gynecology Huang SiCheng
2024-04-18 ~ 2024-04-20 POMR Hemato-Oncology Xia HeXiong
2024-04-11 SOAP Obstetrics and Gynecology Huang SiCheng
2024-03-27 ~ 2024-04-02 POMR Obstetrics and Gynecology Huang SiCheng
[consultation]
[surgical operation]
[chemotherapy]
2025-10-18 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
2025-09-27 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
2025-08-14 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
2025-07-10 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
2025-06-07 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
2024-10-19 - paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-08-13 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-07-15 - [liposome doxorubicin 35mg/m2 60mg D5W 250mL + carboplatin AUC 5 500mg NS 250mL] IP 90min
2024-06-12 - paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-05-21 - paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-04-19 - paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
[Subjective]
[Objective]
[Assessment]
[Plan / Recommendation]
Key insights/summary (2025-10-20)
Problem 1. High-grade serous ovarian carcinoma, FIGO IIIC, on Bevacizumab + Paclitaxel/Carboplatin
Problem 2. Myelosuppression (thrombocytopenia, prior leukopenia) related to cytotoxic chemotherapy
Problem 3. Bevacizumab-associated hypertension risk and BP variability
Problem 4. Hepatitis B reactivation prophylaxis during immunosuppressive therapy
Problem 5. Gastrointestinal symptoms prophylaxis and bowel regimen
Problem 6. Renal function, electrolytes, and hydration during platinum therapy
Problem 7. Asymptomatic cholelithiasis
Problem 8. Port-A maintenance and infection surveillance
Problem 9. Tobacco use
Problem 10. Nutrition and weight maintenance
Medication/treatment-related problems to watch (2025-10-20)
[positive CA125 response to chemotherapy]
The marker CA125 has been steadily decreasing since the initiation of chemotherapy on 2024-04-19, which is a positive sign.
The remaining lab data were unremarkable, with no contraindicating results to prevent proceeding with the new session of chemotherapy scheduled for today.
[optional addition of silymarin for elevated liver enzymes]
The first two sessions of the TP regimen were administered on 2024-04-19 and 2024-05-21. Following the administration, there was a mild elevation remaining in liver enzymes AST and ALT. Adding BaoGan (silymarin) might be considered as an optional supplement.
2024-05-20 AST 40 U/L
2024-05-02 AST 44 U/L
2024-04-25 AST 54 U/L
2024-04-18 AST 38 U/L
2024-05-20 ALT 45 U/L
2024-05-02 ALT 42 U/L
2024-04-25 ALT 56 U/L
2024-04-18 ALT 28 U/L
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
2025-10-28 - irinotecan 180mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 2800mg/m2 2200mg NS 500mL 46hr (FOLFIRI 50%)
2025-09-30 - irinotecan 180mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 2800mg/m2 2200mg NS 500mL 46hr (FOLFIRI 50%)
2025-08-29 - irinotecan 180mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 320mg NS 250mL 2hr + fluorouracil 2800mg/m2 2200mg NS 500mL 46hr (FOLFIRI 50%)
2025-07-11 - leucovorin 20mg/m2 30mg NS 100mL 30min D1-5 + fluorouracil 425mg/m2 685mg NS 100mL 10min D1-5 (CCRT)
2025-06-12 - leucovorin 20mg/m2 30mg NS 100mL 30min D1-5 + fluorouracil 425mg/m2 685mg NS 100mL 10min D1-5 (CCRT)
2025-05-20 - _________________________________________ oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3885mg NS 500mL 46hr (FOLFOX 85% due to old age. no more NHI Avastin left)
2025-04-23 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3885mg NS 500mL 46hr (Avastin + FOLFOX 85% due to old age)
2025-03-24 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3890mg NS 500mL 46hr (Avastin + FOLFOX 85% due to old age)
2025-03-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3860mg NS 500mL 46hr (Avastin + FOLFOX 85% due to old age)
2025-02-14 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2025-01-21 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3160mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-12-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3220mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-12-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3190mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-11-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-10-14 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-09-23 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-09-05 - bevacizumab 5mg/kg 300mg NS 100mL 90min (Avastin)
2024-08-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-07-30 - _________________________________________ irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 466mg NS 250mL 2hr + fluorouracil 2800mg/m2 3264mg NS 500mL 46hr (FOLFIRI 30% off)
Key insights / summary
Problem 1. Metastatic rectal adenocarcinoma on A-FOLFIRI 50% plus Stivarga (regorafenib)
Problem 2. Chemotherapy-associated chronic anemia
Problem 3. Diabetes with hypoglycemia episodes and NPDR OD
Problem 4. GI bleed risk and mucosal protection
Problem 5. Infection risk, prior neutropenia and Candida UTI
Problem 6. Cardiovascular risk and blood pressure on Stivarga (regorafenib)
Problem 7. Nutrition, weight, and albumin
Problem 8. Drug safety, dosing, and interactions
Problem 9. Restaging, goals-of-care, and coordination
Medications today (formatting per rule; verify local brand availability)
The patient is a 69-year-old woman with stage IVA adenocarcinoma of the low rectum, ypT3N1aM1a, grade 3, with left inguinal and pelvic lymph node metastases, KRAS p.G13D mutation. She underwent CCRT and laparoscopic APR (2023-11-30), then multiple systemic therapies (A-FOLFIRI, A-FOLFOX, CCRT with FL) and radiotherapy to para-aortic/iliac nodes (2025-06). Disease has progressed (CT 2025-05-23). She had severe neutropenia, anemia, and Candida UTI in 2025-07, requiring hospitalization. Current systemic therapy includes FOLFIRI (2025-08-29) and Stivarga (regorafenib), started 2025-08-29. Labs show anemia (Hb 8.3 g/dL on 2025-08-28), hypoalbuminemia, but preserved renal/hepatic function. ECOG PS remains 1.
Problem 1. Progressive rectal adenocarcinoma with nodal metastases
Problem 2. Anemia
Problem 3. Neutropenia and infection (not posted)
Problem 4. Nutritional and electrolyte imbalance (not posted)
Problem 5. Cardiovascular comorbidity
Active Medication Review (not posted)
This 69-year-old woman with low rectal adenocarcinoma involving the anus (ypT3N1aM1a, G3, stage IVA), previously treated with CCRT and abdominoperineal resection (2023-11-30), shows evidence of disease progression as of PET (2024-07-08), with new metastatic nodes in the left pelvic side wall and persistent left inguinal lymph node metastases. She is undergoing paraaortic and left common iliac RT (initiated 2025-06-25) combined with Q3W chemotherapy (5-FU + leucovorin), currently completing the second cycle (2025-07-11 to 2025-07-15).
Comorbidities include diabetes mellitus, hypertension, and dyslipidemia. Serial glucose levels show suboptimal control with a spike to 312 mg/dL (2025-07-14). Anemia persists (HGB 10.6 g/dL on 2025-07-11), possibly chemotherapy-related. No active infections or organ dysfunction are evident. Vital signs remain stable.
Problem 1. Progressive rectal adenocarcinoma (ypT3N1aM1a, stage IVA)
Problem 2. Diabetes mellitus with hyperglycemia under chemotherapy
Problem 3. Anemia under chemotherapy (not posted)
Problem 4. Blood pressure fluctuation under treatment (not posted)
Problem 5. Medication safety and polypharmacy (not posted)
[Holistic Treatment Approach] (not posted)
Key insight / summary
Problem 1. Metastatic rectal adenocarcinoma, RAS-mutant, refractory to oxaliplatin/irinotecan lines
Problem 2. Anemia (multifactorial: recent chemotherapy/CCRT myelosuppression, possible occult GI bleed)
Problem 3. History of severe neutropenia with infection during CCRT; current marrow reserve
Problem 4. Anti-VEGF/VEGFR-TKI toxicities risk management (HTN, proteinuria, bleeding, hepatic)
Problem 5. Diabetes mellitus on multi-drug regimen with recent candiduria and ketonuria during illness
Problem 6. Cardiovascular rhythm/conduction issues and antihypertensive regimen
Problem 7. Medication reconciliation and interactions
Problem 8. Nutrition and functional status
Problem 9. Surveillance and restaging
Prioritized treatment suggestions (from most preferred, integrating status and guideline-concordant options)
This 68-year-old woman with metastatic rectal adenocarcinoma (ypT3N1aM1a, G3, stage IVA) has undergone definitive CCRT and APR (2023-11-30), with disease progression documented on PET (2024-07-18: left pelvic and inguinal LN) and CT (2025-02-17: new left iliac LN). Since 2024-07-30, she has been receiving chemotherapy, initially with Avastin + FOLFIRI, later transitioned to Avastin + FOLFOX (from 2025-03-07), and currently continued on FOLFOX alone (NHI covered Avastin exhausted after 2025-04-23).
Recent PET (2025-03-10) shows dissociated response with regression in prior lesions but a new metabolically active iliac LN. Her organ functions remain stable: renal (eGFR 109.88 mL/min/1.73m² on 2025-05-20), hepatic (ALT 12 U/L, AST 19 U/L), and hematologic (WBC 5.5, Hgb 11.1 g/dL, PLT 209), with mild anemia. Glucose variability is noted (114–238 mg/dL). BP is mostly well-controlled (120–175 mmHg systolic), though pulse remains low-normal (HR 60–76 bpm). She remains in ECOG PS 1, afebrile, with good appetite and no nausea/vomiting during most recent FOLFOX cycle (2025-05-20 to 2025-05-22).
Problem 1. Metastatic rectal adenocarcinoma with dissociated PET response
Problem 2. Hematologic toxicity and anemia (not posted)
Problem 3. Chemotherapy-associated hepatotoxicity (resolved) (not posted)
Problem 4. Cardiovascular: Bradycardia and controlled hypertension (not posted)
Problem 5. Glycemic fluctuation under steroid exposure
Problem 6. Chemotherapy-induced nausea (controlled) (not posted)
Since the last review on 2024-12-30, the patient with metastatic rectal adenocarcinoma (ypT3N1aM1a, stage IVA, left inguinal and pelvic LN metastases) has continued chemotherapy (Avastin + FOLFIRI switched to Avastin + FOLFOX on 2025-03-07). Over the past 2.5 months, key developments include:
Problem 1: Disease Progression with New Metastatic LN (2025-02-17 CT)
Problem 2: Cardiovascular Issues – Persistent Bradycardia and Hypertension
Problem 3: Blood Glucose Variability
Active Medication Review
| Medication | Concerns |
|---|---|
| Bevacizumab (Avastin) | Hypertension risk; monitor BP closely. |
| Oxaliplatin (FOLFOX) | Neuropathy risk; monitor for sensory changes. |
| Atenolol (Urosin) | Likely contributing to bradycardia; needs dose review. |
| Olmesartan + Candesartan | Dual ARB therapy; consider reducing to monotherapy. |
| Canagliflozin, Gliclazide, Metformin | Risk of hypoglycemia vs. post-chemo hyperglycemia; monitor trends. |
| Dexamethasone (PRN for chemo) | May be causing hyperglycemia and BP spikes. |
Key Adjustments:
Final Considerations
Next Steps
Conclusion
[Summary]
The patient is a 68-year-old woman with advanced rectal adenocarcinoma (ypT3N1aM1a, stage IVA) involving the anus and metastatic left inguinal lymph node.
She has undergone multiple interventions, including concurrent chemoradiotherapy (CCRT), laparoscopic abdominoperineal resection (APR), and systemic chemotherapy with Avastin (bevacizumab) and FOLFIRI.
The disease has shown progression as of 2024-07-18 per PET/CT. Key issues include hypertension, sinus bradycardia, chemotherapy-related side effects, renal concerns (microalbuminuria due to bevacizumab), and a history of type 2 diabetes mellitus (T2DM), hyperlipidemia, and hypertension.
Lab results and clinical parameters suggest generally stable organ function but highlight specific areas of concern.
[Problems]
Problem 1: Rectal Adenocarcinoma with Metastasis (ypT3N1aM1a, stage IVA)
Problem 2: Sinus Bradycardia with Hypertension
Problem 3: Chemotherapy-Associated Hematuria
[Medication Review]
Current Medications
Medication Adjustments:
Key insights / summary
Problem 1. Bilateral lower-leg erythema and swelling — suspected cellulitis vs inflammatory edema
Problem 2. Edema and 8 kg weight gain over 3 months — possible imatinib-related fluid retention vs cardiorenal vs inflammatory
Problem 3. Gastric GIST, stage IV — on first-line Glivec (imatinib)
Problem 4. Hypocalcemia and bone–mineral metabolism under treatment
Problem 5. Hypothyroidism status post total thyroidectomy — adequacy of replacement unclear
Problem 6. Dyslipidemia management and potential drug interaction
Problem 7. Renal and hepatic function under current therapies
Problem 8. Thromboembolism prevention and mobility during acute infection
Active medication list as of 2025-10-22 (verify administration times)
Follow-up checkpoints (starting 2025-10-23)
[exam finding]
2025-11-04 CXR
2025-10-22 Surgical Pathology Level IV
2025-10-21 ECG
2025-10-01 Sonograpy - neck soft tissue
2025-10-01 Nasopharyngoscopy
2025-09-26 CT - chest
2025-09-24 MRI - nasopharynx
2025-09-15 KUB + L-spine Lat
2025-05-27 Sonography - lower limb artery
2025-01-08 Sonography - lower limb artery
2024-11-05 CT - abdomen
2024-09-24 Sonography - lower limb artery
2024-07-11 Cardiac Catheterization
2024-07-10 ECG
2024-07-10 CXR
2024-07-03 Artery Stiffness
2024-04-24 Sonography - lower limb artery
2023-12-12 Sonography - peripheral vascular
2023-11-02 CT - abdomen
2023-10-05 CT - lower limbs
2023-09-04 2D transthoracic echocardiography
[MedRec]
2025-09-30 SOAP Metabolism and Endocrinology Zhang JiaHui
2025-09-23 ~ 2025-09-27 POMR Neurosurgery Hong LiWei
2025-09-03 SOAP Cardiology Huang XuanLi
2024-07-10 ~ 2024-07-12 POMR Cardiology Huang XuanLi
2021-12-16 ~ 2021-12-30 POMR Cardiac Surgery Xu ZhanYang
2021-12-06 ~ 2021-12-13 POMR Cardiology Zhang YaoTing
Key insights / summary
Problem 1. Metastatic neuroendocrine carcinoma, primary site undetermined
Problem 2. Peri-procedural and ongoing antiplatelet management in cancer care
Problem 3. Hypoglycemia risk and inpatient glycemic strategy
Problem 4. Hepatitis B core antibody positive status before cytotoxic or immunotherapy
Problem 5. Cardiovascular risk management during oncologic therapy
Problem 6. Hematology and coagulation readiness for chemotherapy
Problem 7. Port-A care and procedure-site pain
Problem 8. Supportive care, nutrition, and lifestyle
Problem 9. Electrolytes, renal and hepatic function surveillance during therapy
Problem 10. Differential for right paratracheal thickening and mediastinal nodes
Medications to verify and reconcile (as of 2025-11-05) - Acetal (acetaminophen) QID - Alprazolam (alprazolam) PRN HS - Concor (bisoprolol) QD - Crestor (rosuvastatin 10 mg) QD - Glyxambi (empagliflozin/linagliptin) QD - Plavix (clopidogrel) QD - Pletaal (cilostazol) QD - Relinide (repaglinide) BID - Through (sennoside) HS - Metformin (metformin) BID - ULOSTOP (famotidine) BID
Date: 2025-11-06
Medication- and treatment-related problems, with recommendations and rationales
Key insights / summary
Problem 1. Right supraclavicular and mediastinal lymphadenopathy with splenic lesion, malignancy suspected
Problem 2. Type 2 diabetes mellitus with labile inpatient glucose
Problem 3. Episodic hypertension in a patient with CAD s/p CABG
Problem 4. Secondary prevention for atherosclerotic cardiovascular disease
Problem 5. Neurologic concern and falls with prior right temporal lobe mass
Problem 6. Hematology: thrombocytosis and coagulation status in context of antiplatelets/biopsy
Problem 7. Renal and hepatic function monitoring in a patient with prior nephroureterectomy
Problem 8. Medication reconciliation and polypharmacy considerations
Medication- and treatment-related problems to be concerned, with recommendations and rationales
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
Key insights / summary
Problem 1. Ovarian high-grade serous carcinoma, FIGO IIIC — adjuvant therapy strategy and biomarker work-up
Problem 2. Venous thromboembolism (VTE) risk with persistently high D-dimer
Problem 3. Recurrent hypokalemia and electrolyte management
Problem 4. Cytopenias risk and current hematologic status
Problem 5. Hepatitis B status and antiviral management
Problem 6. Cardiopulmonary baseline and chemo safety
Problem 7. Nutrition, low BMI, and peri-chemo supportive care
Problem 8. Psychosocial symptoms and sleep
Problem 9. Port-A and postoperative status
Active medication reconciliation notes (2025-10-21 to 2025-10-22)
[exam finding]
[medication]
[Subjective]
contact on 2025-10-22 - edema status - she reports peripheral swelling has slightly improved compared with prior days. - no dyspnea, no acute chest pain, no unilateral leg pain reported today. - medication understanding - she is taking Nolvadex (tamoxifen) 10 mg BID since 2021-05-31 and knows it is for recurrence risk reduction. - counseled today that tamoxifen may cause peripheral edema (~11%) and generalized edema (~4%); advised to monitor persistence and patterns. - counseled that tamoxifen is associated with bone fracture risk (~7%; higher in premenopausal patients); not found a prior bone mineral assessment in her records. - goals and concerns - she is open to discussing symptomatic options at next visit if edema persists. - she is agreeable to evaluate bone health screening with her physician.
[Objective]
oncology history - pathology and staging - left breast mucinous carcinoma, grade 2, pT1cN0(sn)M0 stage IA, margins negative, ER 98%+, PR 80%+, HER2 0+, Ki-67 3% (2021-04-20). - treatments completed - breast-conserving surgery with sentinel node biopsy (2021-04-20). - adjuvant radiotherapy 50.0 Gy/25F with 10.0 Gy/5F boost (2021-06-01 to 2021-07-12). - current antineoplastic - Nolvadex (tamoxifen) 10 mg BID, ongoing since 2021-05-31. - disease status - complete response per clinic documentation (2025-03-12). - mammography benign, BI-RADS 2 (2025-03-17). - breast ultrasound BI-RADS 3 left subareolar 0.71×0.58 cm, short-interval follow-up suggested (2025-09-01).
safety-relevant comorbid findings - hepatobiliary - fatty liver with stable right-lobe hemangioma; focal fatty sparing in left lobe (abdominal ultrasound 2025-09-01). - gallbladder polyp 0.44 cm (2025-09-01). - gynecologic - adenomyosis and multiple uterine myomas; endometrial thickness 9.0 mm (pelvic ultrasound 2025-01-08). - prior endometrial polyp resection (2022-06-01). - labs related to recurrence surveillance - CA 15-3 16.8 U/mL and CEA 0.55 ng/mL, both stable and low (2025-09-02).
medication safety notes - adverse effect signal today - mild peripheral edema, improving by report (2025-10-22). - gaps in objective data - no bone mineral density record located in HIS5 to date (search on 2025-10-22). - no recent LFTs presented in the dataset after imaging suggested fatty liver (2025-09-01).
[Assessment]
tamoxifen-associated edema, currently mild and improving - rationale - temporal association with long-term tamoxifen; edema is a known adverse reaction (~11% peripheral, ~4% edema). - no red flags for acute VTE today by history, but tamoxifen increases thromboembolic risk; vigilance warranted. - no evidence that diuretics are routinely required for tamoxifen edema unless persistent, functionally limiting, or secondary causes present.
bone health risk under tamoxifen in a premenopausal patient - rationale - tamoxifen may reduce bone mineral density in premenopausal status and has reported fracture risk (~7%). - no baseline or interval bone mineral density documented; presence of chronic pelvic conditions does not alter need for skeletal assessment. - lifestyle and calcium/vitamin D intake not documented.
hepatic steatosis context on tamoxifen - rationale - imaging shows fatty liver and benign lesions (2025-09-01); tamoxifen exposure can contribute to steatosis in susceptible patients. - absence of recent LFTs limits current safety assessment.
endometrial and gynecologic surveillance while on tamoxifen - rationale - adenomyosis/myomas with endometrial thickness 9.0 mm (2025-01-08) and history of polyp (2022-06-01). - premenopausal status with irregular cycles; tamoxifen warrants symptom-triggered evaluation for abnormal uterine bleeding.
oncologic control and adherence - rationale - disease remains in complete response with benign imaging (2025-03-17) and stable markers (2025-09-02). - ongoing adherence to Nolvadex (tamoxifen) 10 mg BID appropriate toward the planned 5-year course through 2026-05-31.
[Plan / Recommendation]
edema management and VTE safety - nonpharmacologic first line - encourage salt moderation, leg elevation when seated, daily walking, and consider graduated compression stockings if no peripheral arterial disease. - track daily weight and ankle circumference at the same time of day for 1–2 weeks to objectify trend. - when to escalate - if edema persists or worsens for >2–4 weeks, or if functionally limiting, discuss a short, targeted trial of a low-dose diuretic with the physician; rule out secondary causes first. - emergency precautions for VTE: educate to seek urgent care for unilateral leg swelling/pain, sudden dyspnea, chest pain, or hemoptysis at any time.
bone health optimization - diagnostic - request baseline DXA scan of lumbar spine and hip at next oncology or gynecology visit; repeat per result and risk (suggest within 1–2 years if low-normal, earlier if osteopenic). - lifestyle and supplementation - weight-bearing and resistance exercise at least 3 days per week; smoking avoidance and limit alcohol. - ensure elemental calcium 1000–1200 mg/day from diet plus supplements if needed and vitamin D 800–1000 IU/day, adjusted to 25(OH)D level. - pharmacotherapy threshold - if DXA shows osteoporosis or high FRAX risk, discuss antiresorptive therapy options with the physician.
hepatic safety and metabolic counseling - labs - obtain CMP including AST/ALT, ALP, bilirubin within 1–3 months; continue annual monitoring while on tamoxifen or sooner if symptoms arise. - lifestyle - reinforce Mediterranean-style diet, reduced added sugars and refined carbs; regular exercise as above.
gynecologic surveillance - triggers for evaluation - advise prompt clinic contact for any abnormal uterine bleeding, intermenstrual spotting, or new pelvic pain; if present, arrange transvaginal ultrasound with cycle-aware interpretation and consider endometrial sampling. - routine care - continue regular gynecology follow-up while on tamoxifen.
drug interaction and safe-use counseling - avoid and review - avoid strong CYP2D6 inhibitors that may reduce tamoxifen activation (for example, paroxetine, fluoxetine); if antidepressant needed, prefer alternatives with minimal CYP2D6 inhibition after clinician review. - review any new OTC/herbal products for interaction risk; avoid St. John’s wort. - adherence and timing - continue Nolvadex (tamoxifen) 10 mg BID at consistent times; do not double-dose after a miss; report persistent adverse effects.
monitoring timeline and communication - next steps - document today’s counseling and the lack of DXA in HIS5; flag a DXA order suggestion in the next oncology visit note. - request CMP and lipid panel at next lab draw to support hepatic and cardiometabolic monitoring. - schedule reassessment call in 2–4 weeks to recheck edema trend and tolerability unless she is seen earlier in clinic.
patient education provided on 2025-10-22 - summarized risks and warning signs related to edema and VTE. - discussed bone health measures and the plan to ask the physician about DXA at next visit. - confirmed understanding and agreement with the plan.
Key insights / summary
Problem 1. Early-stage left breast mucinous carcinoma — surveillance on endocrine therapy
Problem 2. Tamoxifen-associated gynecologic considerations with adenomyosis/myomas and prior endometrial polyp
Problem 3. Hepatobiliary incidentalomas and fatty liver on surveillance imaging
Problem 4. Endocrine therapy-related vasomotor symptoms and insomnia; post-RT breast skin dryness
Problem 5. Gastrointestinal dyspepsia and constipation tendency
Problem 6. General health maintenance, labs, and safety monitoring
Medications (current, per record)
Follow-up timeline (proposed)
[exam finding]
[MedRec]
2025-10-16 ~ 2025-10-17 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-10-13 SOAP General and Gastroenterological Surgery Zhang YaoRen
2025-10-03 ~ 2025-10-04 POMR General and Gastroenterological Surgery Zhang YaoRen
….-..-..
2025-07-21 SOAP General and Gastroenterological Surgery Zhang YaoRen
2025-05-29 ~ 2025-05-30 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-05-16 ~ 2025-05-17 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-05-02 ~ 2025-05-03 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-04-28, 2025-04-02, 2025-02-10 SOAP General and Gastroenterological Surgery Zhang YaoRen
[radiotherapy]
[Subjective]
Contact and current concerns
[Objective]
Therapies, dosing, and logistics
Hematology, chemistry, and disease activity
[Assessment]
Hematologic toxicity under abemaciclib
Bone health risk on aromatase inhibitor
Therapeutic optimization and travel readiness
[Plan / Recommendation]
Hematology and infection risk mitigation
Travel-specific prevention bundle
Bone health optimization
Ongoing safety labs and follow-up
Medication counseling and adherence
Documentation and coordination
Medications referenced in Brand (generic) format
[Subjective]
Leukopenia and infection susceptibility
[Objective]
Hematology
Clinical findings
[Assessment]
Leukopenia and neutropenia
Treatment appropriateness
[Recommendation]
Leukopenia and infection prevention
Drug management
Supportive care
Follow-up
Key Insights/Summary
Problem 1. Metastatic HR+ breast cancer on abemaciclib + letrozole – disease control and regimen optimization
Problem 2. Chronic leukopenia with borderline grade 2 neutropenia on abemaciclib
Problem 3. Anemia with macrocytosis – mild, chronic
Problem 4. Bone health – osteoporosis under aromatase inhibition, metastatic bone disease history
Problem 5. Hepatic and renal function on therapy – currently stable
Problem 6. Gastrointestinal toxicity risk with abemaciclib – diarrhea prevention and management
Problem 7. Cardiometabolic monitoring under letrozole
Problem 8. Incidental hepatobiliary findings – liver cysts and small gallbladder polyp
Problem 9. Vaccination, infection prophylaxis, and travel-related risk management
Medications referenced in Brand (generic) format
The patient, currently on Verzenio (abemaciclib) and Femara (letrozole), is undergoing combination endocrine therapy for hormone receptor–positive, HER2–negative breast cancer. The current regimen aligns with NCCN-recommended first-line treatment for postmenopausal patients or patients with ovarian suppression, targeting tumor proliferation via CDK4/6 inhibition and estrogen synthesis suppression. The primary concerns are potential hematologic suppression, hepatic function changes, gastrointestinal toxicity (notably diarrhea from abemaciclib), and bone health deterioration from aromatase inhibition. Current lab results (2025-08-07) show preserved renal and hepatic function, stable electrolytes, and adequate albumin, suggesting tolerability so far. However, ongoing surveillance for neutropenia, hepatotoxicity, and musculoskeletal side effects is essential.
Problem 1. Breast cancer – hormone receptor–positive, HER2–negative, on abemaciclib + letrozole therapy
Problem 2. Hematologic toxicity – leukopenia and possible neutropenia from abemaciclib
Problem 3. Bone health risk – aromatase inhibitor-associated osteoporosis
Problem 4. Gastrointestinal toxicity risk – abemaciclib-associated diarrhea (not posted)
[lab data]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-10-20 - Trodelvy (sacituzumab govitecan) 10mg/kg 360mg NS 250mL 3hr
2025-10-14 - Trodelvy (sacituzumab govitecan) 10mg/kg 360mg NS 250mL 3hr
2025-09-22 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2025-09-01 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2025-08-06 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2025-07-11 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2025-06-05 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2025-05-06 - Keytruda (pembrolizumab) 200mg NS 100mL 30min
2024-07-04 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr + paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 360mg NS 250mL 2hr
2024-06-06 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr + paclitaxel 175mg/m2 248mg NS 250mL 3hr + carboplatin AUC 5 380mg NS 250mL 2hr
2024-05-14 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 258mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2024-04-11 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 256mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2024-03-19 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 256mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2024-02-16 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 258mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2024-01-16 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2023-12-25 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2023-12-05 - …………………………………… paclitaxel 175mg/m2 257mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
2022-08-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
2022-07-25 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
2022-07-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
2022-06-08 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
2022-05-09 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
2022-04-19 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
Title Levothyroxine / Magnesium Salts
Dependencies
Route: Only oral preparations of magnesium salts are expected to participate in this interaction.
Risk Rating D: Consider therapy modification
Summary Magnesium Salts may decrease serum concentrations of Levothyroxine. Severity Moderate Reliability Rating Intermediate-Low
Patient Management Separate administration of oral levothyroxine and oral magnesium salts by at least 4 hours.
Magnesium Salts Interacting Members Almagate, Diomagnite, Magaldrate, Magnesium Aspartate, Magnesium Carbonate, Magnesium Chloride, Magnesium Citrate, Magnesium Glucoheptonate, Magnesium Gluconate, Magnesium Glycerophosphate, Magnesium Glycinate, Magnesium Hydroxide, Magnesium L-aspartate Hydrochloride, Magnesium L-lactate, Magnesium Oxide, Magnesium Salicylate, Magnesium Sulfate, Magnesium Trisilicate Exceptions (agents listed are discussed in separate interaction monograph[s] or are non-interacting) Dolomite
Discussion Prescribing information for levothyroxine lists aluminum- and magnesium-containing antacids as agents that may prevent absorption of T4 from the gastrointestinal tract, and recommends that such agents be administered at least 4 hours apart from levothyroxine.1 At least one report describes a patient receiving stable levothyroxine therapy whose serum thyrotropin concentrations became elevated during treatment with a magnesium-containing antacid, and returned to normal values following cessation of the antacid.2 An in vitro study found that combinations of magnesium hydroxide, magnesium carbonate, and aluminum hydroxide were capable of adsorbing levothyroxine in a dose-dependent manner, but that magnesium oxide alone did not significantly adsorb levothyroxine.2
The likely primary mechanism of this interaction is adsorption of levothyroxine to magnesium and/or aluminum in the gastrointestinal tract.
Key insights/summary (as of 2025-10-21)
Problem 1. Metastatic endometrioid carcinoma with bilateral lung metastases, progression after pembrolizumab; now on Trodelvy (sacituzumab govitecan)
Problem 2. Chronic kidney disease stage 3 with recent AKI-I, now improved
Problem 3. Normocytic anemia, grade 2
Problem 4. Chronic hepatitis B core positive on prophylaxis
Problem 5. Immune-related hypothyroidism on replacement
Problem 6. Hypomagnesemia and electrolyte vigilance during Trodelvy
Problem 7. Severe underweight, hypotension, and cachexia risk
Problem 8. Gastrointestinal symptoms prevention during Trodelvy
Problem 9. Infection risk surveillance
Problem 10. Peripheral neuropathy and sensorineural hearing loss
Problem 11. Vascular access and thrombosis/bleeding safety
Current medications of note (verify dosing to renal function and schedule)
As of 2024-02-16, the patient demonstrates stable vital signs and grossly normal laboratory values (2024-02-15). Entecavir (Baraclude) is currently utilized for the management of Anti-HBc positivity. No medication discrepancies were identified.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Summary
Problem 1. Obstructive jaundice due to suspected ERBD occlusion with impending/ongoing cholangitis
Problem 2. Metastatic pancreatic ductal adenocarcinoma (PDAC), on Gemzar/Abraxane
Problem 3. Suspected bacteremia/sepsis risk associated with biliary obstruction and central lines
Problem 4. Electrolyte balance with history of renal potassium wasting (low renin/low aldosterone physiology)
Problem 5. Glycemic management in type 2 diabetes during acute illness
Problem 6. Hematologic status and coagulation
Problem 7. Pain control and prior drug eruption
Problem 8. Biliary/vascular access management
Problem 9. Nutrition and hepatic function support
Medication and treatment–related problems to be concerned about (as of 2025-10-16) and recommendations with rationales
Monitoring checklist today
Key Insights / Summary
Problem 1. Pancreatic cancer with vascular invasion and new liver metastasis
Problem 2. Hypokalemia with renal K+ loss, low renin and aldosterone
Problem 3. Glycemic control in type 2 diabetes mellitus (not posted)
Problem 4. Supportive care and general condition (not posted)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[Radiotherapy]
[immunochemotherapy]
[Subjective]
Medication follow-up
[Objective]
Key clinical background
Medications on record
[Assessment]
Adherence and safety
Immunosuppression risk
DAPT and PPI interaction
Lipid secondary prevention
Hyperuricemia/gout risk with CKD
Renal dosing and drug considerations
Education needs and monitoring
[Plan / Recommendation]
Medication optimizations
Monitoring and labs
Safety counseling and lifestyle
Care coordination and follow-up
Improvement opportunities
Summary
Problem 1. Post-NSTEMI CAD s/p mid-LAD DES (2025-07-30), secondary prevention
Problem 2. Extranodal marginal zone B-cell lymphoma (pulmonary MALT), c-stage IV, on rituximab
Problem 3. ESBL E. coli UTI with sepsis, now clinically resolved
Problem 4. Prostate disease: adenocarcinoma (Gleason 4+3) on right with BPH and obstruction
Problem 5. Chronic lung disease and pleural disease (COPD; prior large L pleural effusion)
Problem 6. CKD stage 3 and renal/urate metabolism
Problem 7. Hematology: anemia of chronic disease pattern, thrombocytopenia trend, eosinophilia
Problem 8. Gastroesophageal protection and antiplatelet interaction
Problem 9. Indeterminate bone scan hot spot, degenerative spine disease
Problem 10. Dermatologic lesions status post total excision; SK education
Problem 11. Functional status and rehabilitation
Problem 12. Current medication reconciliation and safety notes
[exam finding]
2025-09-01 Sonography - abdomen
2025-09-01 Mammography
2025-06-11 CT
….-..-..
2023-04-13 Pathology
2023-03-27 Mammography
2022-07-29 Pathology - breast excisional biopsy with surgical margin
2020-08-03 Pathology - breast mastectomy with regional lymph nodes
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Subjective]
Pharmacist counseling
[Objective]
Medication and treatment history - Current endocrine therapy - Femara (letrozole 2.5 mg) 1# QD with recurring 28-day × 3 (84-day) refills documented from 2021-02-08 through 2025-09-08. - Supplements (historical) - Bio-Cal chewable tablet (tribasic calcium phosphate 1203 mg & cholecalciferol 330 IU) 1# BID was prescribed on 2021-02-08.
Imaging and pathology context - Breast cancer primary and adjuvant therapy completed - Partial mastectomy + SLNB (2020-07-31); EC ×4 then docetaxel ×4 (2020-08-14~2020-12-25); adjuvant RT whole breast + boost (2021-01-28~2021-03-15). - Surveillance findings - Mammography: minimal residual clustered microcalcifications at left UOQ, follow-up advised (Mammo 2025-09-01). - Liver: new 3.4 × 2.07 cm iso-to-hyperechoic mass at right lobe on sonography (US 2025-09-01); prior CT reported no focal hyper-/hypo-vascular tumor (CT 2025-06-11).
Selected labs relevant to bone and safety - Calcium 2.37 mmol/L (2020-07-30); hepatic panel within normal ranges on multiple dates (e.g., ALT 10 U/L, TBil 0.44 mg/dL on 2024-01-02). - Glycemic profile: HbA1c 6.0% (2024-06-17), fasting glucose 94 mg/dL (2024-06-17). - No DEXA result is found in the chart to date.
[Assessment]
AI-associated bone health risk under long-term letrozole - Aromatase inhibition reduces estrogen and accelerates bone loss; fracture risk increases after the first 1–2 years and persists thereafter during therapy. - She has been on continuous AI for >4 years without a documented baseline or follow-up DEXA; this is a care gap needing correction. - She had calcium/vitamin D supplementation in 2021, but ongoing adherence and dosing adequacy are unclear.
Oncologic surveillance and medication safety - Current endocrine regimen is guideline-concordant for her stage and biology; nearing 5-year mark, the benefit of extension must be balanced against bone/CV risks. - Minimal left-breast microcalcifications are stable (Mammo 2025-09-01). - New hepatic lesion requires definitive characterization (US 2025-09-01 vs CT 2025-06-11), independent of stable tumor markers; medication counseling should support prompt imaging follow-up.
Cardiometabolic considerations on AI - AIs may worsen lipids and slightly increase ischemic events with prolonged use. - HbA1c is 6.0% (2024-06-17), suggesting mild cardiometabolic risk; lipid data are not present, representing a monitoring gap.
[Plan / Recommendation]
Bone health optimization and monitoring - Order and prioritize DEXA - Recommend baseline DEXA now (2025-10) given >4 years of AI without prior scan; repeat every 1–2 years depending on the result. - Consider vertebral fracture assessment if height loss/back pain is reported. - Ensure adequate calcium/vitamin D and lifestyle - Target ~1200 mg elemental calcium/day and vitamin D 800–1000 IU/day; check 25(OH)D and correct if low. - Encourage weight-bearing/resistance exercise, smoking cessation, and fall-prevention (home safety review). - Pharmacotherapy if indicated - If osteopenia/osteoporosis or high FRAX risk: initiate antiresorptive therapy (e.g., alendronate weekly or denosumab q6mo) after dental evaluation and counseling on adherence and hypocalcemia risk.
Endocrine therapy counseling and documentation - Continue Femara (letrozole 2.5 mg) 1# QD; reinforce adherence and adverse-effect self-monitoring (arthralgia, myalgia, hot flashes). - At the next oncology visit, prepare a shared decision discussion on stopping at 5 years vs extending to 7.5–10 years, explicitly weighing fracture/CV risks against modest DFS benefit in node-negative, low-risk disease. - Document a clear endocrine plan and expected end date or extension criteria.
Oncologic follow-up for hepatic lesion - Reinforce timely imaging - Advise scheduling contrast-enhanced liver MRI with hepatobiliary phase and diffusion (MRI 2025-10) as recommended by surgery/oncology. - If indeterminate, proceed to multiphase CT or CEUS; biopsy if required by radiology/oncology.
Cardiometabolic and general safety monitoring - Request fasting lipid panel and ASCVD risk calculation (2025-10); repeat per primary care/oncology protocol during AI therapy. - Maintain annual HbA1c and blood pressure surveillance; intensify lifestyle counseling (dietary pattern, activity, weight). - Drug interaction and safety review - Avoid concurrent tamoxifen; review OTC/supplements (e.g., calcium products) for dosing/spacing to minimize GI upset and ensure adherence. - Reinforce hazardous drug handling precautions for oral antineoplastics per institutional policy.
Patient education and follow-up - She is reminded to ask the physician about DEXA at the upcoming visit (2025-10-15); provide a written checklist including DEXA, lipid panel, and liver MRI scheduling. - Arrange follow-up call in 1–2 weeks to confirm orders placed, imaging scheduled, and to reconcile supplements/AI adherence.
Guideline alignment (summary):
Bottom line: to date, her treatment (BCT + RT, adjuvant EC→docetaxel, then letrozole) is consistent with NCCN. As she approaches 5 years of AI, discuss whether to stop at 5 years vs extend, weighing her low-risk pathology against bone risks, and tighten bone-health measures.
Summary
Problem 1. New hepatic lesion (oncologic significance to rule out)
Problem 2. Long-term adjuvant endocrine therapy strategy (approaching year 5)
Problem 3. Bone health under aromatase inhibitor therapy
Problem 4. Cardiometabolic surveillance on AI therapy
Problem 5. Left breast microcalcifications with prior benign pathology
Problem 6. Autoimmune thyroid disease, currently euthyroid
Problem 7. Hematologic profile and treatment-related cytopenias (historical)
Problem 8. Urinary tract infection in 2022, resolved
Problem 9. Use of serum tumor markers in surveillance
Medications (current/relevant)
Follow-up Plan Checklist (next 4–6 weeks)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Key insights / summary
Problem 1. Ovarian clear cell carcinoma with peritoneal carcinomatosis, p53-aberrant, MMR-intact, HER2-positive
Problem 2. Venous thromboembolism (extensive right-leg DVT with suspected PE) with IVC filter
Problem 3. Anemia with reactive thrombocytosis and leukocytosis, iron-restricted pattern
Problem 4. HBV exposure with risk of reactivation during chemotherapy
Problem 5. H. pylori-positive chronic active gastritis
Problem 6. Nutrition risk and hypoalbuminemia
Problem 7. Hepatobiliary involvement and liver function monitoring
Problem 8. Renal/urinary issues: recurrent microscopic hematuria and nephrolithiasis
Problem 9. Electrolytes and general labs surveillance
Problem 10. Pain and symptom control; functional and device status
Problem 11. Cardiopulmonary baseline
Planned monitoring summary
[lab data]
2025-03-12 HBV DNA PCR (quan) 508 IU/mL
2025-03-11 HBeAg Nonreactive
2025-03-11 HBeAg Value 0.392 S/CO
2025-02-26 HBsAg (NM) Positive
2025-02-26 HBsAg Value (NM) 434
2025-02-26 Anti-HBc (NM) Positive
2025-02-26 Anti-HBc Value (NM) 0.009
2025-02-26 Anti-HCV (NM) Negative
2025-02-26 Anti-HCV Value (NM) 0.034
2025-02-26 Anti-HBs (NM) Negative
2025-02-26 Anti-HBs value (NM) <2.0 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Key Insight / Summary
Problem 1. Persistent/recurrent UTI after September Klebsiella bacteremia
Problem 2. Peri-operative readiness for Port-A removal (elective 2025-10-14)
Problem 3. DLBCL response status after R-CHOP x6 (possible progression in neck)
Problem 4. Hematology trends and anemia (microcytosis)
Problem 5. Electrolyte disturbances (mild hyponatremia and hypokalemia)
Problem 6. Diabetes management in the inpatient and peri-operative setting
Problem 7. HBV reactivation prophylaxis under rituximab exposure
Problem 8. BPH with LUTS contributing to UTI risk
Problem 9. Opportunistic infection history and prophylaxis
Problem 10. Current medication reconciliation (selected active inpatient meds as of 2025-10-12/2025-10-13)
The patient is a 74-year-old male with diffuse large B-cell lymphoma (DLBCL), Lugano stage II, undergoing R-CHOP chemotherapy using liposomal doxorubicin. He is currently admitted for suspected neutropenic fever following Cycle 5 of chemotherapy (administered on 2025-06-12). ANC dropped to 968/µL on 2025-06-24, and temperature reached 38.5°C since 2025-06-22. Other comorbidities include type 2 diabetes mellitus, hypertension, and HBV carrier status. Clinical exam and vitals are stable; chest X-ray showed nonspecific right upper lobe infiltrates. No obvious infectious source from urinalysis or GI/GU systems. Empirical antibiotics initiated. Glycemic control is suboptimal (glucose 254 mg/dL on 2025-06-24).
Problem 1. Neutropenic fever post-chemotherapy
Problem 2. Myelosuppression following R-CHOP (Cycle 5)
Problem 3. Hyperglycemia in setting of diabetes and infection (below not posted)
Problem 4. Chemotherapy response and disease status
Problem 5. HBV carrier under chemotherapy
[exam finding]
[MedRecNo]
2025-10-04 ~ 2025-10-12 POMR Hemato-Oncology Liu YiSheng
[therapy]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Key insights / summary
Problem 1. High-grade serous ovarian carcinoma with malignant pleural effusion (cT3N0M1a, stage IVA)
Problem 2. Malignant pleural effusion (currently minimally symptomatic)
Problem 3. Preoperative cardiopulmonary risk and ECG abnormalities
Problem 4. Hematologic tolerance to chemotherapy (neutropenia recovered; mild anemia persists)
Problem 5. Organ function status and chemotherapy dosing fitness
Problem 6. HBV exposure with ongoing cytotoxic/biologic therapy (reactivation prophylaxis)
Problem 7. Gastrointestinal symptoms/constipation risk under chemotherapy and antiemetics
Problem 8. Venous thromboembolism (VTE) risk in advanced cancer and perioperative period
Problem 9. Port-A catheter care and infection prevention
Problem 10. Differential of appendiceal primary versus ovarian primary (clarification/completeness)
[Medication]
2022-03-31 ~ on_going - Arimidex (anastrozole 1mg) 1# QD
2021-04-15 ~ 2022-03-30 - Femara (letrozole 2.5mg) 1# QD
2021-03-11 ~ 2021-03-25 - Nolvadex (tamoxifen citrate 10mg) 1# BID
[Subjective]
Contact and purpose
[Objective]
Breast cancer history and treatments
Endocrine therapy timeline
Surveillance imaging
Laboratory markers and organ function
Other imaging
Documentation gaps
[Assessment]
Breast cancer status and therapy appropriateness
Bone health risk under AI therapy
AI tolerability and supportive care
Medication safety and interactions
[Plan / Recommendation]
Communication and follow-up
Endocrine therapy
Bone health optimization
Surveillance
Symptom management and education
Key insights / summary
Problem 1. Right breast DCIS s/p BCS + SLNB + RT, current surveillance negative
Problem 2. Endocrine therapy plan and tolerability (Arimidex [anastrozole] ongoing)
Problem 3. Bone health under long-term AI therapy
Problem 4. Breast density and imaging strategy optimization
Problem 5. Benign breast/axillary findings (cysts, fibroadenomas, ductal dilatation)
Problem 6. Gynecologic symptom history (postmenopausal bleeding once noted 2021-04-15)
Problem 7. Incidental hepatobiliary and renal findings (hemangioma, gallstone, renal cyst)
Problem 8. Genetic risk assessment
Problem 9. Organ function overview
Problem 10. Post-operative functional status and lymphedema risk
Problem 11. Endocrine therapy modification rationale and guideline alignment
[lab data]
2025-10-07 CA-153 (NM) 446.100 U/ml
2025-07-29 CA-153 (NM) 246.900 U/ml
2025-06-24 CA-153 (NM) 152.280 U/ml
2025-06-21 CA-153 124.9 U/mL
2025-06-03 CA-153 (NM) 121.200 U/ml
2025-05-13 CA-153 (NM) 99.390 U/ml
2025-05-06 CA-153 (NM) 84.690 U/ml
2025-04-08 CA-153 (NM) 74.900 U/ml
2025-03-26 CA-153 (NM) 56.010 U/ml
2025-03-18 CA-153 (NM) 52.240 U/ml
2024-11-25 CA-153 (NM) 31.830 U/ml
2024-11-07 CA-153 (NM) 34.740 U/ml
2024-09-03 CA-153 (NM) 30.214 U/ml
2024-08-23 CA-153 (NM) 34.522 U/ml
2024-07-30 CA-153 (NM) 27.914 U/ml
2024-07-12 CA-153 (NM) 23.933 U/ml
2024-07-09 CA-153 (NM) 20.884 U/ml
2024-06-28 CA-153 (NM) 16.859 U/ml
2024-06-13 CA-153 (NM) 16.723 U/ml
2023-11-03 CA-153 (NM) 14.854 U/ml
[exam finding]
[MedRec]
[radiotherapy]
[medication]
Kisqali FC (ribociclib) 200mg 3# QD
Aromasin (exemestane) 25mg QD PO prescribed on
Afinitor (everolimus) 10mg QD PO prescribed on
Nolvadex (tamoxifen citrate) 10mg BID PO prescribed on
Xgeva (denosumab) 120mg SC prescribed on
[Subjective]
Disease/treatment context
Current concerns and caregiver report
[Objective]
Oncologic status and imaging
Performance and vitals
Key laboratory trends
Current medication list (post-discharge / OPD)
[Assessment]
Therapeutic appropriateness and safety
[Plan / Recommendation]
Immediate safety and monitoring
Drug interaction mitigation and regimen optimization
Molecularly guided next steps (deferred until recovery)
Bone health, calcium/vitamin D and analgesia
Nutrition and supportive care
Key insight/summary
Problem 1. Metastatic HR+/HER2- breast cancer, progression with poor performance status
Problem 2. Recurrent malignant pleural effusions with dyspnea
Problem 3. Severe cytopenias: thrombocytopenia, neutropenia, anemia
Problem 4. Hepatic metastases with transaminitis and very high LDH; hypoalbuminemia and edema
Problem 5. Electrolyte disorders and right hydronephrosis/hydroureter
Problem 6. Delirium/anxiety, insomnia, and poor intake with NG tube support
Problem 7. Extensive bone metastases; pain and skeletal event prevention
Problem 8. Infection/sepsis episode during admission, now improved but high risk
Problem 9. Cardiopulmonary comorbidity and dyspnea contributors
Medication streamlining and safety notes - Stop disease-directed: Kisqali (ribociclib). Consider stopping Aromasin (exemestane) if no symptomatic benefit. - Hold/avoid: Xgeva (denosumab) given hypocalcemia and dental history; NSAID patches (flurbiprofen) cautiously if platelets very low; Cimetidine can be switched to a PPI if reflux symptomatic. - Continue only comfort-focused meds: Tramacet (tramadol/acetaminophen) PRN; Utapine (quetiapine) HS; antiemetics/laxatives; low-dose opioids for dyspnea/pain.
Care coordination and next steps - Arrange hospice referral, home oxygen if needed, home nursing for NG/pleural catheter if placed, and family meeting to confirm DNR and preferred site of care. - De-emphasize routine lab/imaging; perform only if results will change comfort measures. - Provide caregiver teaching for breakthrough dyspnea/pain protocols and when to call for help.
All statements are supported by the timeline: imaging (CT 2025-09-12; CXR 2025-09-23; MRI 2025-07-01), pathology (liver 2025-06-24; pleural cytology 2025-09-12), tumor markers (CA15-3 series 2024-07-09→2025-10-07), labs and notes (CBC/chemistry 2025-09→2025-10; Discharge 2025-09-27; SOAP 2025-10-07; Psycho-Oncology 2025-09-19).
Key insights / summary
Problem 1. Recurrent malignant pleural effusion with dyspnea/risk of decompensation
Problem 2. HR+/HER2– metastatic breast cancer, radiologic and serologic progression; endocrine + CDK4/6 just started
Problem 3. Life-threatening thrombocytopenia with prior neutropenia and chronic anemia
Problem 4. Acute kidney injury with right hydronephrosis/hydroureter
Problem 5. Hepatic involvement with transaminitis and very high LDH
Problem 6. Electrolyte/acid–base abnormalities with QT-risk implications
Problem 7. Cardio-pulmonary reserve and QT-safety while on ribociclib
Problem 8. Nutrition, delirium/anxiety, and goals of care
Problem 9. Bone metastases and skeletal event prevention
Medications checklist and immediate safety actions (today)
Monitoring plan (prioritized)
[Kisqali FC (ribociclib) tube feeding]
The Kisqali FC (ribociclib) tablet is film-coated, not enteric-coated. This means that if it needs to be crushed and dissolved for administration, it will not cause staining and can be given to the patient immediately after preparation.
Source: Confirmed with Novartis representative Ms. Yang on 2024-10-04 (at 0928-812-181)
[surgical operation]
[Subjective]
Medication counseling visit with spouse present (2025-10-08).
He reports almost no regular exercise, low daily water intake, and minimal vegetable consumption; constipation persists despite magnesium oxide.
Pharmacist reinforced anticoagulation education: the importance of maintaining INR within target for mechanical valves and atrial fibrillation, recognizing bleeding and thrombosis warning signs, and keeping daily vitamin K intake consistent.
Lifestyle counseling delivered:
[Objective]
Anticoagulation and key labs
Cardiovascular/structural history supporting anticoagulation
Cerebrovascular history
Metabolic profile and renal function
Current medication list per recent prescriptions and chart
[Assessment]
Anticoagulation for double mechanical valves with atrial fibrillation; labile INR, currently near-target
Diabetes mellitus type 2; improving control with SGLT-2/DPP-4 combo plus metformin
Atherogenic dyslipidemia with residual hypertriglyceridemia/low HDL on statin
Constipation with low fiber/fluid intake; on magnesium oxide
Cerebrovascular secondary prevention status
Medication safety/adherence
[Plan / Recommendation]
Anticoagulation optimization
Lifestyle and constipation management
Diabetes care
Dyslipidemia
Arrhythmia/heart function monitoring
Safety and abstinence
Key insights/summary
Problem 1. Anticoagulation for mechanical valves and atrial fibrillation (labile INR)
Problem 2. Prosthetic valve status post redo AVR and prior MVR
Problem 3. Cerebrovascular disease: basilar artery occlusion s/p EVT; peri-operative MCA embolic infarcts
Problem 4. Diabetes mellitus type 2 (suboptimal control, improving)
Problem 5. Atherogenic dyslipidemia (hypertriglyceridemia, low HDL)
Problem 6. Renal function and electrolytes (overall preserved; peri-operative fluctuations)
Problem 7. Arrhythmia and rate control
Problem 8. Hematology: post-operative anemia resolved; thrombocytopenia episodes resolved
Problem 9. Pulmonary status: prior aspiration pneumonia/COPD-like changes
Problem 10. Medication reconciliation and adherence
For this patient — with both mechanical aortic and mitral valves and atrial fibrillation — the target INR range should follow the 2020 ACC/AHA and 2021 ESC/EACTS valvular heart disease guidelines, as well as CHEST 2021 antithrombotic therapy recommendations.
Key guidance:
Summary table (for quick reference):
| Valve type / Clinical context | Target INR | Rationale |
|---|---|---|
| Mechanical AVR (bileaflet, no risk factors) | 2.0–3.0 | Standard |
| Mechanical AVR (On-X, isolated, no AF, on aspirin) | 1.5–2.0 | FDA-approved specific condition |
| Mechanical MVR | 2.5–3.5 | High thrombosis risk |
| Double mechanical (AVR + MVR) | 2.5–3.5 | Combined risk |
| Any mechanical + AF or prior embolism | 2.5–3.5 | Additive risk |
Therefore, for this patient with both mechanical AVR and MVR, plus atrial fibrillation and prior embolic stroke, the appropriate INR target range is 2.5–3.5 (target 3.0).
Yes, the physician’s reduction of warfarin from 2.5 mg daily (2025-10-01) to 1.5 mg daily (2025-10-08) makes pharmacological and clinical sense when viewed in context of this patient’s recent INR trajectory and history of warfarin sensitivity.
Stepwise reasoning:
Evidence from INR trend
Interpretation: a 150% relative increase in dose (from 1.0 to 2.5 mg) caused INR to rise rapidly from 1.0 to 2.4 within just 7 days, showing that the patient is highly sensitive to warfarin, likely due to factors such as age, diet fluctuations, comorbidities, and drug interactions.
Possible pharmacokinetic/pharmacodynamic contributors
Clinical reasoning for dose reduction
Summary rationale
In short, the physician’s reduction from 2.5 mg to 1.5 mg was preventive and pharmacologically sound, reflecting:
Is it possible that the doctor’s target INR 2.0-2.5?
It’s possible — but unlikely appropriate for this specific patient.
Here’s the reasoning:
Summary:
| Possible target range | Evidence | Guideline conformity | Comment |
|---|---|---|---|
| 2.5–3.5 | Standard for double mechanical valves, AF, prior stroke | Yes | Guideline-consistent; ideal for thrombosis prevention |
| 2.0–2.5 | Implied by recent dose decrease at INR 2.42 | No (off-label lower target) | May reflect individualized bleeding risk management |
Conclusion: It is possible that the doctor is intentionally
maintaining INR near 2.0–2.5 to minimize bleeding risk due to prior INR
instability and patient fragility.
However, strictly speaking, this deviates from standard guidelines,
which recommend 2.5–3.5 (target 3.0) for this combination of prostheses
and atrial fibrillation.
[exam finding]
[exam finding]
[MedRec]
[consultation]
2025-10-01 Rehabiliation
2025-09-22 Hemato-Oncology
2025-09-16 Urology
[surgical operation]
[chemotherapy]
Key insights / summary
Problem 1. Advanced left UTUC with renal vein invasion and regional nodes, on neoadjuvant gemcitabine/cisplatin
Problem 2. Complicated UTI history with VRE E. faecium and candiduria, now improved
Problem 3. Myelosuppression risk and cytopenia dynamics after C1
Problem 4. Renal function and electrolyte stewardship with cisplatin
Problem 5. Ototoxicity risk with pre-existing SNHL
Problem 6. Cardiovascular status: hypertension, Grade II LV diastolic dysfunction, mild AR
Problem 7. HBV core antibody positive on antiviral prophylaxis
Problem 8. Diabetes with steroid-associated dysglycemia
Problem 9. Dementia, functional decline, and disposition risk
Problem 10. Neurologic weakness with cerebrovascular exclusion
Problem 11. Nutrition and frailty
Problem 12. Pain and constipation
Problem 13. Vascular access care and infection prevention
Current active medications (as of 2025-10-07)
Key follow-ups to place today (2025-10-07)
[exam finding]
Diagnosis: - Heart size: Normal ( LA volume:33 ml , LA volume
index:24 ml/m²) - Thickening: None - Pericardial effusion: None - LV
systolic function: Normal - RV systolic function: Normal - LV wall
motion: Normal - MV prolapse: None ; - MS: None ; - MR: None ; - AS:
None ; Max AV velocity = 0.94 m/s , - AR: None ; - AVS(aortic valve
sclerosis): NCC, RCC - TR: None ; - TS: None ; - PR: None ; - PS: None ;
- Mitral E/A = 65 / 101 cm/s (E/A ratio = 0.64) ; Dec.time = 269 ms ;
Heart rate = 82 bpm - Septal MA e’/a’ = 7.5 / 10 cm/s ; Septal E/e’ =
8.8 ; - Lateral MA e’/a’ = 6.6 / 11.8 cm/s ; Lateral E/e’ = 9.9 ; -
Intracardiac thrombus : None - Vegetation : None
- Congential lesion : None - Calcified lestions : aortic valve, mitral
chordae; aortic root; - IVC size 10 mm with inspiratory collapse >50%
- Conclusion: - Indeterminated LV filling pressure. - Normal LV and RV
systolic function. - Aortic valve sclerosis and mild aortic root
calcification.
Key insights / summary
Problem 1. Severe thrombocytopenia with acute anemia (new pancytopenia trend)
Problem 2. Pneumonia with sepsis physiology and hypoxemia risk
Problem 3. EGFR exon19del metastatic lung adenocarcinoma with brain and bone metastases
Problem 4. Hyperbilirubinemia with chronic liver parenchymal disease and gallstone
Problem 5. Infection- and steroid-related dysglycemia
Problem 6. QT prolongation risk and medication safety
Problem 7. Renal and electrolyte status
Problem 8. Chronic hepatitis B on antiviral prophylaxis
Problem 9. Nutrition, functional status, and supportive care
Current medication snapshot (key agents as of 2025-10-04 to 2025-10-07)
Disposition note
[exam findings]
2025-10-16 Pathology - lymphnode biopsy
2025-10-13 Surgical Pathology
2025-10-02
2025-10-02 PCN - pigtail revision
2025-09-19 2D transthoracic echocardiography
2025-09-16 CT
2025-08-20 PCN - pigtail revision
2025-08-20 Sonography - nephrology
2025-07-18 CT - abdomen
[MedRec]
2025-10-01 ~ 2025-10-17 POMR Hemato-Oncology Gao WeiYao
2025-08-18 ~ 2025-08-27 POMR Hemato-Oncology Gao WeiYao
[consultation]
[surgical operation]
[chemotherapy]
Key insights / summary (2025-11-04)
Problem 1. Metastatic vaginal adenocarcinoma with inguinal progression, post multiple lines
Problem 2. Urinary tract obstruction with bilateral PCN and recurrent catheter dysfunction/UTI
Problem 3. Post-chemotherapy cytopenias with persistent anemia
Problem 4. Recent sepsis/pneumonia vs UTI-associated systemic inflammation, now improved
Problem 5. Chronic kidney disease stage 2–3a, medication dosing considerations
Problem 6. Cancer-related pain and bilateral lower-limb lymphedema
Problem 7. Anticoagulation: indication/dose verification for apixaban
Problem 8. Chronic hepatitis B on antiviral prophylaxis
Problem 9. Nutrition and functional status
Medication-related considerations and safety checks (2025-11-04)
Monitoring plan
Summary
Problem 1. Metastatic vaginal adenocarcinoma (pT2bN1M1, stage IV)
Problem 2. Chronic bilateral ureteral obstruction with recurrent right and left PCN dysfunction
Problem 3. Normocytic anemia (HGB 9.1 g/dL) (not posted)
Problem 4. Viral hepatitis B carrier (anti-HBc positive, HBsAg negative) (not posted)
Problem 5. Right lower extremity lymphedema and pain
This is a 58-year-old woman with recurrent, metastatic vaginal adenocarcinoma (pT2bN1M1, FIGO stage IV) with bilateral inguinal lymph node and right thigh involvement. After progressing through multiple chemotherapy regimens including taxanes, cisplatin, carboplatin/irinotecan, GFL, and pembrolizumab, she was recently initiated on sacituzumab govitecan (Trodelvy) with the most recent dose given on 2025-05-19. She has chronic bilateral hydronephrosis secondary to malignant ureteral obstruction, status post multiple bilateral PCN revisions (latest on 2025-05-20). Current condition is stable under immunotherapy, with preserved renal function, mild anemia, and controlled pain.
Problem 1. Refractory metastatic vaginal adenocarcinoma (stage IV, pT2bN1M1)
Problem 2. Bilateral malignant ureteral obstruction with CKD, status post PCN revision
Problem 3. Anemia of chronic disease and chemotherapy (not posted)
Problem 4. Bilateral lower limb lymphedema
Problem 5. Pain control and symptom monitoring during chemotherapy (not posted)
This is a 58-year-old woman with a history of moderately differentiated adenocarcinoma of the vagina, initially diagnosed as pT2bN1, FIGO stage III in 2022, now with progression to stage IV due to bilateral inguinal lymph node metastases and right thigh metastasis (Pathology 2024-06-06). She underwent staging surgery, CCRT, and multiple systemic regimens including cisplatin-paclitaxel-bevacizumab, carboplatin-irinotecan, GFL, and currently receiving pembrolizumab Q3W (most recent on 2025-03-31). Renal function has been chronically compromised, now requiring bilateral percutaneous nephrostomy (2024-11-18, 2024-11-19), and she has atrial flutter (ECG 2025-02-10), severe hydronephrosis (multiple imaging), and signs of progressive soft tissue metastatic disease.
Problem 1. Progressive Vaginal Adenocarcinoma (Stage IV)
Problem 2. Bilateral Hydronephrosis with Chronic Kidney Disease (not posted)
Problem 3. Atrial Flutter with AV Block
Problem 4. History of Venous Thromboembolism (VTE)
Problem 5. Skin and Soft Tissue Lesions (R’t Thigh/Pubic Region)
[Patient Review and Assessment]
The patient is a 58-year-old female with a history of vaginal adenocarcinoma (pT2bN1, FIGO Stage III), which has progressed to bilateral inguinal lymph node metastasis (current stage IV), confirmed by imaging and biopsy. She has undergone multiple rounds of chemotherapy (e.g., carboplatin, paclitaxel), radiation, and surgical interventions, including bilateral ureteral stent placements to manage hydronephrosis due to tumor compression. Recent findings also suggest right femoral vein thrombosis and recurrent complications related to tumor burden and treatment toxicity.
Current Symptoms and Complications
Treatment Remmendations and Rationale
Balancing Efficacy and Toxicity in Vaginal Cancer Therapy
[nab-paclitaxel and renal function]
Post-administration of nab-paclitaxel, serum creatinine levels have consistently remained above 1.5 mg/dL. Although there hasn’t been a rapid increase, continuous monitoring is still advised.
Nab-Paclitaxel for patients with altered kidney function, there are no dosage adjustment recommendations for those with a Creatinine Clearance (CrCl) ≥30 mL/minute. Furthermore, there are no pharmacokinetic studies available for severe kidney impairment in patients with a CrCl <30 mL/minute.
[exam finding]
[MedRec]
[immunochemotherapy]
Key insights / summary
Problem 1. Severe chemotherapy-associated marrow suppression (neutropenia, thrombocytopenia, anemia)
Problem 2. Etiologic clarification of cytopenias (disease vs treatment vs consumption)
Problem 3. Safety of immediate post-chemo environment
Key insights / summary
Problem 1. Hyperleukocytosis with circulating blasts and suspected leukostasis
Problem 1. Hyperleukocytosis with circulating blasts and suspected leukostasis (old version, not used)
Problem 2. Coagulopathy consistent with DIC in hematologic malignancy
Problem 3. Tumor lysis syndrome (TLS), spontaneous/ongoing risk
note for problem 3 (not for post) - The reason to stop routine sodium bicarbonate in tumor lysis syndrome (TLS) unless there is metabolic acidosis is based on both physiology and guideline recommendations:
Problem 4. Severe thrombocytopenia with bleeding risk
Problem 5. Anemia of marrow failure with transfusion dependency
Problem 6. Definitive lymphoma management strategy (high-risk MCL, leukemic phase)
Problem 7. Electrolyte/metabolic derangements
Problem 8. Hypogammaglobulinemia and infection risk
Problem 9. Pleural effusions and cardiopulmonary status
Problem 10. Renal and hepatic function
Immediate checklist (next 6–12 hours)
[Differential diagnosis (descending probabilities) — based ONLY on the provided labs] (not for post)
Key concomitant syndromes suggested by labs (supporting malignant acute leukemia picture)
Summary ranking (from most to least likely based on labs alone)
Notes/next lab steps to refine lineage (still within ‘labs only’ scope)
[exam finding]
[immunochemotherapy]
Key insights / summary
Problem 1. Hodgkin lymphoma, staging and initial therapy selection
Problem 2. Treatment readiness: cardiac, pulmonary, hepatic, renal
Problem 3. Tumor lysis syndrome risk and prevention
Problem 4. Chemotherapy-induced nausea and vomiting (CINV) prophylaxis
Problem 5. Infection risk, antibiotics, and growth factor strategy
Problem 6. Hepatitis B/C screening and reactivation mitigation
Problem 7. Venous access and thrombosis/line care
Problem 8. Fertility, survivorship, and lifestyle
Problem 9. Hematology, electrolytes, and general monitoring
Current medications and immediate adjustments
[lab data]
[exam findings]
2025-08-25 L-spine flex & ext (including sacrum)
2025-08-25 KUB + L-spine Lat
2025-08-18 Pelvis = THR & Rt Hip Lat
2025-07-15 Pelvis - THR
2025-07-13 ECG
2025-07-08 Pelvis - THR & Rt Hip Lat
2025-06-18 CT - abdomen
2025-05-07 Kidney Sonography - urology
2025-05-05 L-spine flex & ext (including sacrum)
2025-05-05 KUB
2025-03-26 CT - abdomen
2025-03-10 KUB + L-spine Lat
2025-01-23 Pathology - intervetebral disc
2025-01-08 Bone densitometry - spine + hip
2025-01-02 MRI - L-spine
….-..-..
2023-11-16 CT - abdomen
2023-11-07 KUB
2023-11-07 SONO - kidney (urology)
2023-11-07 Bladder Sonography
2023-09-06 CXR
….-..-..
2022-09-14 CT - abdomen
….-..-..
2021-08-16 Pathology - vaginal biopsy
[MedRec]
[surgical operation]
[chemotherapy]
Key insights/summary
Problem 1. Suspected recurrent ovarian carcinoma with rising tumor markers and abdominal pain (old version, not used)
Problem 1 should be amended to align with NCCN v3.2025 for recurrent epithelial ovarian cancer: confirm platinum sensitivity (last Paraplatin [carboplatin]-based therapy 2024-12-04 → relapse ≥6 months, thus platinum-sensitive) and complete tumor molecular testing before selecting recurrence therapy or immunotherapy. Immediate treatment for a biochemical-only relapse is category 2B; observation until clinical relapse is acceptable after shared decision-making. Molecular profiling (HER2, BRCA1/2, HRD, MSI/MMR, TMB, FRα, RET, NTRK, etc) is recommended if not already done, and renal function must be considered when choosing agents.
Problem 1. Recurrent ovarian carcinoma — suspected biochemical/clinical relapse, treatment selection per NCCN v3.2025
Problem 2. Obstructive uropathy with chronic right ureteral double-J stent and recurrent complicated UTI
Problem 3. Chronic kidney disease stage 3b–4 (eGFR ~22–24) with atrophic left kidney
Problem 4. Uncontrolled hypertension on admission
Problem 5. Normocytic anemia, likely anemia of CKD/chronic disease
Problem 6. Hypokalemia, mild
Problem 7. Hyperuricemia with cardiovascular disease history
Problem 8. HBV resolved infection with prior antiviral exposure; impending immunotherapy
Problem 9. Post–right hip bipolar hemiarthroplasty and osteoporosis on Prolia
Problem 10. Antiplatelet management and bleeding risk coordination
Ancillary
Follow-up checkpoints (next 72 h)
[MedRec]
[Subjective]
Medication-related history and concerns
[Objective]
Key diagnoses and timeline
Vital signs and examinations
Imaging and cardiac function
Laboratory trends
Pleural fluid (right) 2025-09-17
Current and recent medications
[Assessment]
Secondary prevention after NSTEMI and CABG
Bleeding risk and antiplatelet intensity
UTI with E. coli bacteremia, completing therapy
Post-CABG pleural effusion, right-dominant, improving
Transient severe hepatocellular injury, resolved
Blood pressure and volume status
GI protection and potential bleeding
Sleep and CNS depressants
Adherence, safety, and education gaps
[Plan / Recommendation] 2025-10-01 pharmacist proposals for 2025-10-02 clinic
Cardiovascular secondary prevention
Antiplatelet and bleeding management
Infection management
Pulmonary and pleural effusion follow-up
Electrolyte and renal monitoring
Sleep and CNS safety
Wound care and rehabilitation
Medication reconciliation and education
Monitoring and tests to order on 2025-10-02
Return and red flags
Coordination
Key Insights/Summary
Problem 1. Post-CABG pleural effusion with dyspnea, right-dominant (bloody), improving
Problem 2. Urinary tract infection with E. coli bacteremia, improving
Problem 3. Recent NSTEMI with LM + 3VD s/p CABG (secondary prevention optimization)
Problem 4. Pneumonia vs postoperative atelectasis-related changes, improving
Problem 5. Gastrointestinal occult blood positivity while on antiplatelet therapy
Problem 6. Transient severe hepatocellular injury, resolved
Problem 7. Hematologic abnormalities perioperatively, resolved
Problem 8. Electrolyte and renal status, currently stable
Problem 9. Hypertension and risk factor control
Problem 10. Wound care and rehabilitation after CABG, left GSV harvest site delayed healing
Problem 11. Sleep disturbance/anxiety (post-hospital), PRN sedative use
Medication Reconciliation and Optimization (2025-10-01)
Follow-up/Monitoring Plan
Deep commentary on the plan snippet
Bottom line for 2025/10/02 OPD
[exam]
[MedRec]
[surgical operation]
[chemotherapy]
[exam finding]
[consultation]
[immunochemotherapy]
[note]
R-mini-CHOP (rituximab 375 mg/m2, cyclophosphamide 400 mg/m2, doxorubicin 25 mg/m2, vincristine 1 mg on day 1 of each cycle, 40 mg/m2 prednisone on days 1 to 5) [Lancet Oncol. 2011;12(5):460].
He has CD20-positive stage II DLBCL of the right maxillary/buccal region with orbital extension, on Pola-R-CHP q3w (C1 2025-07-09, C2 2025-08-06, C3 2025-09-01, C4 2025-09-30). Interim CT neck shows marked nodal regression with a residual infiltrative focus in the right masticator space (CT 2025-09-02). He experienced grade 4 neutropenia and thrombocytopenia after C3 (WBC 1.05×10^3/µL, ANC ≈0.10×10^3/µL; PLT 77×10^3/µL on 2025-09-10) with rapid count recovery (CBC 2025-09-17) and currently has macrocytic anemia (HGB 10.6 g/dL, MCV 103.4 fL on 2025-09-30). New marked eosinophilia (AEC ≈1.55×10^3/µL on 2025-09-30) and a creatinine rise from baseline (0.80→1.11 mg/dL; eGFR 101.28→69.41 mL/min/1.73m^2 between 2025-09-17 and 2025-09-30) require evaluation. Glycemia is suboptimally controlled around steroid pulses (glucose 243 mg/dL on 2025-08-31; bedside 192 mg/dL on 2025-10-01 05:34). HBV core antibody is positive with undetectable DNA and he is on Vemlidy (tenofovir alafenamide) prophylaxis. Vital signs remain stable and oxygenation is normal (SpO2 97–98% on 2025-09-30).
Problem 1. DLBCL treatment response and on-therapy assessment
Problem 2. Post-chemotherapy cytopenias with recovery
Problem 3. Macrocytic anemia
Problem 4. Marked eosinophilia
Problem 5. Renal function decline (baseline normal)
Problem 6. Infection surveillance and prior left lower lung infiltrate
Problem 7. HBV reactivation risk under anti-CD20 therapy
Problem 8. Cardiovascular safety under anthracycline
Problem 9. Steroid-related hyperglycemia in diabetes
Problem 10. New lower-extremity edema
Problem 11. Ocular and craniofacial involvement
Problem 12. Supportive care and prophylaxis checklist
Problem 13. Electrolyte and metabolic status
Problem 14. Nutrition, rehabilitation, and survivorship
The patient is diagnosed with diffuse large B-cell lymphoma (DLBCL), CD20-positive, stage II involving the right maxillary and buccal regions with orbital extension. He is currently receiving Polatuzumab Vedotin plus R-CHP (Pola-R-CHP) chemotherapy. As of 2025-08-06, he demonstrates preserved hepatic and renal function, no signs of tumor lysis syndrome, stable hematologic parameters aside from borderline anemia, and no electrolyte disturbances. Current laboratory trends are consistent with good treatment tolerance. However, persistent eosinophilia and a declining hemoglobin trend require closer attention.
Problem 1. Tumor Response and Disease Monitoring
Problem 2. Hematologic Abnormalities (Anemia and Eosinophilia)
Problem 3. Renal Function Status (not posted)
Problem 4. Electrolyte and Metabolic Stability (not posted)
Problem 5. Hepatic Function and Risk of Drug-Induced Liver Injury (DILI) (not posted)
Problem 6. HBV Reactivation Risk (not posted)
[MedRec]
[Subjective]
Visit context
[Objective]
Cardiovascular disease timeline and key data
Laboratory and imaging
Current medications at discharge (7 days supplied since last discharge on 2025-09-25)
[Assessment]
Post-PCI secondary prevention and DAPT education
Intermittent sharp chest pain post-PCI
Lipid management intensity
Glycemic risk and SGLT2 inhibitor question
Renal function and potassium
Tobacco dependence and lung screening
Drug interaction and safety review
[Plan / Recommendation]
DAPT and secondary prevention
Chest pain safety net and evaluation
Electrolyte optimization and renal monitoring
Glycemic risk management
Smoking cessation
Medication administration and interaction counseling
Follow-up and monitoring schedule
Documentation of patient education
Key insights / summary
Problem 1. STEMI due to LAD-P lesion, s/p DES (secondary prevention & DAPT)
Problem 2. Severe dyslipidemia (secondary prevention lipid target)
Problem 3. Tobacco dependence
Problem 4. Diastolic dysfunction (impaired LV relaxation) with preserved LVEF
Problem 5. Potassium and ventricular arrhythmia risk
Problem 6. Renal function post-contrast exposure
Problem 7. Prediabetes / glycemic risk
Problem 8. Leukocytosis
Problem 9. Residual D1 stenosis and ischemia surveillance
Problem 10. Access site and medication safety/education
Problem 11. Pulmonary finding on admission CXR
Follow-up checkpoints and monitoring plan
[exam finding]
[MedRec]
[immunochemotherapy]
Key Insights / Summary
Problem 1. Advanced high-grade serous ovarian carcinoma on C6; biochemical response
Problem 2. Suspected umbilical surgical wound fistula/infection
Problem 3. Post-induction maintenance strategy planning
Problem 4. Bevacizumab-associated labile hypertension
Problem 5. Persistent mild hypercalcemia with inappropriately elevated PTH
Problem 6. Macrocytosis with mild anemia, treatment-related
Problem 7. Organ function: hepatic and renal status adequate for therapy
Problem 8. HBV core antibody reactive under cytotoxic therapy; antiviral prophylaxis
Problem 9. Chemotherapy toxicities: neuropathy G1, alopecia G2, fatigue/anorexia G1
Problem 10. Cardiometabolic comorbidities and peri-steroid glycemic excursions
Follow-up Checklist
Key Insights / Summary
Problem 1. Advanced high-grade serous ovarian carcinoma on C5 paclitaxel/carboplatin/bevacizumab, initial response
Note for problem 1 (not posted): The recommendation for maintenance therapy after frontline chemotherapy in advanced ovarian cancer is based on large phase III randomized trials and NCCN 2025 guidelines. The rationale is as follows:
(below not posted)
Problem 2. Bevacizumab-associated hypertension, currently improved but labile
Problem 3. Mild hypercalcemia with inappropriately high PTH; improved after hydration
Problem 4. Volume depletion signal (isolated BUN elevation) around chemotherapy
Problem 5. Macrocytosis with mild anemia, chemotherapy-associated; B12/folate replete
Problem 6. HBV core antibody reactive on cytotoxic therapy; antiviral prophylaxis in place
Problem 7. Chemotherapy-related toxicities: neuropathy G1, alopecia G2, fatigue/anorexia G1; cutaneous folliculitis
Problem 8. Cardiometabolic comorbidities and steroid-related glycemic excursions
Problem 9. Anti-VEGF renal safety and thromboembolism surveillance
Problem 10. Psycho-oncology and sleep
Follow-up and Monitoring Checklist
This is a 50-year-old woman with newly diagnosed high-grade serous carcinoma of the ovary, FIGO stage IIIC (pT3c), status post optimal debulking surgery on 2025-05-19, and currently receiving combination chemotherapy with paclitaxel, carboplatin, and Avastin (bevacizumab), with cycles administered on 2025-06-13 and 2025-07-04. Her disease is complicated by peritoneal carcinomatosis and grade 4 fatty liver. Comorbidities include chronic hepatitis B (Anti-HBc reactive, non-viremic), hypertension, and allergic rhinitis. She is currently clinically stable with good ECOG performance (PS 1), controlled blood pressure, acceptable glycemic control (HbA1c 6.1% on 2025-06-27), and no significant cytopenias or organ dysfunction. CA125 has decreased (224.6 on 2025-04-29 → 38.31 on 2025-06-16), suggesting treatment response.
Problem 1. High-grade serous ovarian carcinoma, FIGO stage IIIC
Problem 2. Liver function and hepatic risk (grade 4 fatty liver, HBV carrier)
Problem 3. Hematologic profile and chemotherapy tolerance
Problem 4. Glycemic control and hypertension
[Lab data]
2025-07-01 MPO stain Negtive
2025-07-01 CAE stain Negtive
2025-07-01 ANAE stain Negtive
2025-06-30 CMV_IgG Reactive
2025-06-30 CMV_IgG Value 140.5 AU/mL
2025-06-30 CMV IgM Nonreactive
2025-06-30 CMV IgM Value 0.10 Index
2025-06-24 HLA A-high 02:07
2025-06-24 HLA A-high 24:02
2025-06-24 HLA B-high 15:12
2025-06-24 HLA B-high 54:01
2025-06-24 HLA C-high 01:02
2025-06-24 HLA C-high 03:03
2025-06-24 HLA DQ-high 04:01
2025-06-24 HLA DQ-high 05:02
2025-06-24 HLA DR-high 04:05
2025-06-24 HLA DR-high 15:02
2025-06-24 PML-RARA fusion gene Undetectable
[exam finding]
[MedRec]
2025-09-25 10:00 Family Meeting - Conditioning Regimen
2025-06-26 ~ 2025-08-05 POMR Hemato-Oncology Gao WeiYao
2025-06-07 ~ 2025-06-21 POMR Hemato-Oncology Gao WeiYao
2025-06-06 SOAP Hemato-Oncology Gao WeiYao
[consultation]
2025-08-27 Colorectal Surgery
2025-08-22 Nephrology
2025-07-10 Urology
2025-07-09 Colorectal Surgery
2025-06-26 Infectious Disease
2025-06-11 Colorectal Surgery
[chemotherapy]
2025-09-16 - cytarabine 30mg/m2 50mg BID SC 2min D1-5
2025-08-18 - cytarabine 30mg/m2 50mg BID SC 2min D1-5
2025-07-16 - cytarabine 30mg/m2 50mg BID SC 2min D1-5
2025-06-16 - cytarabine 30mg/m2 50mg BID SC 2min D1-5
2025-05-05 - idarubicin 12mg/m2 D1-3 + cytarabine 200mg/m2 D1-7 (at MacKay Hospital)
The patient is a 60-year-old male with acute myeloid leukemia (AML) with complex cytogenetics, refractory to induction chemotherapy and with poor response to multiple low-dose regimens (e.g., cytarabine, venetoclax). He remains profoundly pancytopenic, transfusion-dependent, and at high risk of infectious complications (cellulitis, anal fistula, recurrent bacteremia/urinary infection). Renal function is impaired (Cr 1.6, eGFR ~46), and electrolytes show recurrent disturbances. Despite these risks, he is scheduled for haploidentical peripheral blood stem cell transplantation (PBSCT) from his son, with a myeloablative conditioning (Fludarabine/Busulfan/ATG/TBI) and GVHD prophylaxis with PTCy, mycophenolic acid, cyclosporine. The question is whether this approach is the best and most life-saving option given his disease biology and clinical condition.
Problem 1. Refractory acute myeloid leukemia with complex cytogenetics
Problem 2. Organ function status and transplant fitness
Problem 3. Infectious complications and immunosuppression risk
Problem 4. Metabolic and electrolyte derangements
Overall deliberation
Conditioning regimen planned for this patient (per family meeting record 2025-09-25):
Is there a name for this regimen?
MAC or RIC?
Rationale
Conclusion
[GPT4o]
The patient is a 60-year-old male with AML transformed from MDS, now receiving low-dose cytarabine (50 mg BID SC, most recently from 2025-09-16 to 2025-09-20). He remains in a profoundly pancytopenic state (WBC 0.2 ×10^3/uL, PLT 31 ×10^3/uL, HGB 7.2 g/dL on 2025-09-24), complicated by ongoing infectious risks (e.g., right lower leg cellulitis, persistent CRP elevation, procalcitonin 2.3 ng/mL on 2025-09-24), renal impairment (Cr 1.62, eGFR 46.4), cholestatic pattern of liver dysfunction (direct bilirubin 1.27), and metabolic imbalances (Na 149, K 3.6). Imaging shows splenomegaly, gallstones, and stable echocardiographic findings. Multiple transfusions, anti-infective agents, and supportive measures have been applied. His condition remains critical but hemodynamically stable.
Problem 1. Persistent pancytopenia with evolving marrow failure
Problem 2. Neutropenic fever and evolving infection risk
Problem 3. Renal impairment with risk of acute-on-chronic kidney injury
Problem 4. Hyperbilirubinemia with cholestatic trend
Problem 5. Electrolyte abnormalities: Hypernatremia, hypokalemia, mild hypocalcemia
Problem 6. Splenomegaly with cytopenia contribution
Problem 7. Functional status and palliative considerations
Key Insight / Summary
The patient is a 60-year-old male with acute myeloid leukemia (AML) characterized by complex cytogenetics including del(3)(p21), -7, and multiple marker chromosomes (BM cytogenetics 2025-07-02), initially refractory to 7+3 induction (idarubicin + cytarabine from 2025-05-05 to 2025-05-11). He is currently on reinduction with venetoclax + low-dose cytarabine with posaconazole prophylaxis, undergoing his second cycle from 2025-07-16 to 2025-07-21. The course is complicated by persistent pancytopenia, neutropenic sepsis with ICU admission, atrial fibrillation with RVR, obstructive uropathy, mucositis, and now evidence of new ischemic ECG changes. As of 2025-08-14, he is afebrile, hemodynamically stable, but persistently pancytopenic and transfusion-dependent, with concerning cardiac ischemic signs and limited functional status.
Problem 1. Acute myeloid leukemia with complex cytogenetics
Problem 2. Pancytopenia and neutropenia-related complications (not posted)
Problem 3. New ECG ischemic changes and cardiovascular risk
Problem 4. Sepsis and antimicrobial therapy (not posted)
Problem 5. Gastrointestinal and mucosal complications (not posted)
Problem 6. Functional status and prognosis (not posted)
The patient is a 60-year-old male with newly diagnosed acute myeloid leukemia (AML) harboring complex cytogenetics and poor initial response to induction chemotherapy (idarubicin + cytarabine from 2025-05-05 to 2025-05-11). Reinduction therapy was shifted to a low-intensity regimen of venetoclax + low-dose cytarabine + posaconazole starting 2025-06-16, repeated again 2025-07-16 to 2025-07-21. The patient experienced complications including neutropenic sepsis with septic shock requiring ICU care in late June, persistent pancytopenia, and recurrent mucosal and wound infections. As of 2025-07-21, the patient remains pancytopenic (ANC 7), afebrile, and functionally limited (ECOG PS 2), with mild respiratory symptoms and ongoing transfusion and antimicrobial support.
Problem 1. Acute myeloid leukemia with complex karyotype
Problem 2. Pancytopenia with neutropenic status
Problem 3. Sepsis with septic shock, resolved (below not posted)
Problem 4. Cardiovascular comorbidity: Atrial fibrillation and prior ischemia
Problem 5. Lower urinary tract symptoms with retention
Problem 6. Mucositis and nutritional compromise
[Labs on Cytochemical stains, CMV Serology, HLA Typing, PML-RARA fusion] (not posted)
Cytochemical stains (2025-07-01) - These are cytochemical stains used to help classify leukemias, especially acute leukemias:
CMV Serology (2025-06-30) - Used to determine past or current infection with cytomegalovirus (CMV):
HLA Typing (2025-06-24)
PML-RARA fusion gene (2025-06-24)
Result: Undetectable
Interpretation:
[exam finding]
[surgical operation]
[MedRec]
[Radiotherapy]
2023-06-09 ~ 2023-07-10 - 4000cGy/20 fractions of the metastatic tumor over right upper lung.
2017-12-13 ~ 2018-02-13 - 5000cGy/25 fractions of the right maxilla, oral cavity, peripheral involved, to bilateral neck, 6600cGy/33 fractions of the right maxillary tumor bed and peripheral involved area.
[chemotherapy]
Key insights / summary
Problem 1. Metastatic ACC with progressive pulmonary disease
Problem 2. Current systemic therapy: CAP regimen appropriateness and safety
Problem 3. Possible locoregional recurrence at parapharyngeal/pterygoid region
Problem 4. Cardio-oncology risk with anthracycline exposure and coronary disease
Problem 5. Cisplatin nephrotoxicity and electrolyte wasting risk
Problem 6. Myelosuppression and infection risk
Problem 7. Hepatic function and drug handling
Problem 8. Pulmonary status and symptom control
Problem 9. Concomitant medications, analgesia, and gastroprotection
Problem 10. Constipation risk and antiemetic adjuncts
Problem 11. Nutrition, function, and survivorship planning
Problem 12. Follow-up imaging and measurable outcomes
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
Patient reported on 2025-09-24 that the planned procedure from
2025-08-27 was not performed because the anesthesiologist could only
provide 4 hours of support time.
- Patient acknowledged awareness of having atrial fibrillation and
understood it carries a risk of thrombus formation.
- Patient stated that she intentionally reduced intake of green leafy
vegetables in recent days, believing this would reduce clot risk.
- Patient confirmed she has an outpatient appointment arranged in the
afternoon of 2025-09-24 to discuss future treatment plans.
- Patient also mentioned having read the warfarin education booklet
previously provided and attempted to follow recommendations.
[Objective]
Anticoagulation history
- Warfarin regimen since 2025-08-27: Cofarin (warfarin) 5 mg 0.5# QD
(2.5 mg daily) plus Cofarin (warfarin) 1 mg 0.5# QW135 (0.5 mg extra on
dialysis days), total dose = 2.5 mg on non-dialysis days and 3 mg on
dialysis days.
INR/PT monitoring
- 2025-08-27: INR 1.51, PT 15.6 sec.
- 2025-09-15: INR 2.39, PT 23.9 sec.
- 2025-09-19: INR 1.84, PT 18.7 sec.
- 2025-09-24: INR 2.85, PT 28.2 sec.
Other findings
- Labs (2025-09-19): Hb 11.0 g/dL, PLT 146 x10^3/uL, Creatinine 6.56
mg/dL, eGFR 6.93 mL/min/1.73m², Na 135 mmol/L, K 3.9 mmol/L, CRP <0.1
mg/dL.
- ECG (2025-09-19): atrial fibrillation with RVR, left anterior
fascicular block, lateral infarct (age undetermined).
- CXR (2025-09-19): cardiomegaly, widened mediastinum, hilar engorgement
with interstitial changes.
[Assessment]
Anticoagulation control
- INR on 2025-09-24 (2.85) slightly exceeded the physician’s intended
therapeutic target range (2.0–2.5).
- The patient’s recent reduction in vegetable intake likely lowered
vitamin K intake, augmenting warfarin effect.
- Additional complexity comes from the variable dosing regimen (2.5 mg
vs 3 mg depending on dialysis days), which increases the chance of
fluctuation or adherence issues.
- Given persistent LA thrombus on TEE (2025-08-27), anticoagulation
remains essential, but close monitoring is needed to balance thrombotic
and bleeding risks.
Procedural planning
- The planned LAA occlusion on 2025-08-27 was deferred for logistical
reasons. Delay prolongs the patient’s exposure to both AF-related
thrombus risk and anticoagulation-related bleeding risk.
Patient knowledge/behavior
- Patient is motivated, reads educational material, and is aware of AF
risks. However, she attempted self-modification of diet with the goal of
“improving” anticoagulation, which inadvertently increased INR.
[Plan / Recommendation]
Warfarin management
- Reinforce consistent dietary vitamin K intake; advise against
intentional large fluctuations.
- Consider simplifying regimen to a fixed daily dose (e.g., 2.5 mg
daily) if clinically acceptable, to reduce confusion and
variability.
- Continue frequent INR monitoring; recheck within 3–5 days after diet
stabilized, especially if INR remains >2.5.
Procedure follow-up
- Encourage patient to discuss with cardiology regarding rescheduling of
LAA occlusion, as thrombus risk persists with AF and dilated LA.
Education and support
- Reinforce key points from warfarin education booklet: importance of
stable diet, regular INR testing, and recognizing signs of
bleeding.
- Provide counseling on coordinating anticoagulation plan with dialysis
schedule, ensuring clarity on exact dosing days.
Collaboration
- Communicate findings and recommendations with cardiology and
nephrology teams for integrated management.
OLD VERSION (not posted)
[Subjective]
contact and anticoagulation counseling - the patient states the previously scheduled 2025-08-27 inpatient procedure did not proceed because the anesthesiologist could only support 4 hours - the patient understands she has atrial fibrillation and that AF increases thromboembolic risk - after reviewing INR 2.85 (2025-09-24), the patient reports she intentionally reduced intake of green vegetables recently - the patient’s intention was to “make clot formation less likely” by raising INR - she has an outpatient visit arranged for the afternoon on 2025-09-24 and agrees to inform the physician about dietary changes and to discuss next-step plans, including the previously planned but deferred procedure
[Objective]
anticoagulation data and pertinent cardiopulmonary findings - INR / PT trend - INR 2.85, PT 28.2 sec (2025-09-24, STAT) - INR 1.84, PT 18.7 sec; APTT 37.9 sec (2025-09-19) - INR 2.39, PT 23.9 sec; APTT 44.7 sec (2025-09-15) - prior INR 1.51 (2025-08-27), 2.11 (2025-08-13) - rhythm / structure - ECG: atrial fibrillation with rapid ventricular response; LAFB; lateral infarct-age undetermined (2025-09-19) - CXR: cardiomegaly, mediastinal widening, bilateral hilar engorgement with increased interstitial markings (2025-09-19) - TEE: severely dilated LA with dynamic faint LAA thrombus 3.45×1.2 cm² and spontaneous echo contrast (2025-08-27) - Chest CTA: no LAA thrombus detected (2025-08-27) - renal / dialysis context - ESRD on hemodialysis QW135; labs consistent with ESRD (Cr 6.56, eGFR 6.93 on 2025-09-19) - current anticoagulant (per recent course) - Cofarin (warfarin) 5mg 0.5# QD plus 1mg 0.5# QW135 prescribed on 2025-08-27; subsequent INRs as above
[Assessment]
anticoagulation stability and diet–warfarin interaction - INR has risen to 2.85 (2025-09-24) outside the stated target 2.0–2.5 after the patient intentionally reduced vitamin K intake - pattern is consistent with a diet-driven increase in warfarin effect; no new bleeding reported - given history of LAA thrombus on TEE (2025-08-27) and AF with RVR (2025-09-19), anticoagulation remains indicated; however, overshooting the target increases bleeding risk (AV shunt site vulnerability, ESRD-related platelet dysfunction)
procedure planning and communication gaps - the planned 2025-08-27 LAA occlusion did not proceed for logistical reasons; thromboembolic risk remains - bridging plans, peri-procedural anticoagulation strategy, and re-scheduling require coordinated discussion with cardiology/anesthesia
ESRD considerations - ESRD increases variability of anticoagulation control and bleeding risk; intradialytic anticoagulation (heparin) may need fine-tuning when INR is high - recent APTT values (37.9–44.7 sec on 2025-09-19 to 2025-09-15) do not by themselves explain INR elevation but support a cautious approach
[Plan / Recommendation]
optimize INR toward 2.0–2.5 and stabilize inputs - diet - counsel the patient to return to her usual daily amount of green vegetables and maintain consistency day-to-day (avoid intentional restriction intended to ‘thin blood’) - provide examples of stable portions and a simple log template to record greens intake for the next 1–2 weeks - warfarin - if diet is returned to baseline today, continue Cofarin (warfarin) 2.5 mg QD and recheck INR in 3–5 days (by 2025-09-27 to 2025-09-29) - if INR remains >2.5 despite dietary stabilization, consider a small dose reduction (e.g., 2.5 mg on 5 days per week and 2.0 mg on 2 days per week) with follow-up INR in 3–5 days; adjust only one lever at a time (dose or diet) to identify the driver - reinforce avoidance of new OTC/supplements (e.g., NSAIDs, fish oil, herbal products) without review
coordinate with dialysis and cardiology regarding high-INR days and procedure re-planning - dialysis unit - if INR >2.5, request evaluation of intradialytic heparin dosing or heparin-minimized protocol to reduce access-site oozing risk - cardiology / anesthesia - at today’s visit (2025-09-24), ask the patient to report the intentional vitamin K restriction and the current INR 2.85 - discuss re-scheduling LAA occlusion and establish a peri-procedural anticoagulation plan (target INR window, hold timing, intradialytic anticoagulation on peri-op days) - consider repeat TEE if clinically indicated to reassess LAA thrombus status before proceeding
safety monitoring and education
[Subjective]
warfarin INR follow-up
medication understanding and adherence
[Objective]
INR and coagulation profile
bleeding risk and symptoms
[Assessment]
warfarin therapeutic effect restored
no current evidence of under- or over-anticoagulation
[Plan / Recommendation]
maintain current warfarin dose
monitor INR trend
reinforce education on consistent vitamin K intake
safety and adherence
[Subjective]
warfarin anticoagulation follow-up
warfarin target range clarification
[Objective]
INR trend and dosage adjustment
[Assessment]
persistent supratherapeutic INR despite dose reduction
potential mismatch between dosing and dietary pattern
[Plan / Recommendation]
optimize warfarin INR control through combined dose and diet adjustment
monitor and educate
recheck INR in 3–5 days after dose and diet changes to evaluate effect
provide printed warfarin education booklet
Key Insight / Summary
Problem 1. Supratherapeutic INR under warfarin therapy
Problem 2. Refractory paroxysmal atrial fibrillation with thrombus and hemodynamic burden
Problem 3. End-stage renal disease with worsening renal markers
Problem 4. Progressive atherosclerotic cardiovascular disease with coronary and aortic involvement
Problem 5. Anemia in ESRD with mild thrombocytopenia
This is a 56-year-old female with end-stage renal disease (on hemodialysis), refractory atrial fibrillation complicated by a sizable left atrial thrombus (TEE 2025-07-30), pulmonary hypertension, and chronic obstructive pulmonary disease. She has been anticoagulated with warfarin, with recent INR titration showing appropriate therapeutic levels (INR 3.22 on 2025-08-01), but had a complication of persistent oozing from her left AV shunt site post-hemodialysis on 2025-08-04. This poses a dilemma in balancing thromboembolic prevention with bleeding risk, especially given her high CHA2DS2-VASc score and left atrial thrombus. Other systems remain largely compensated. Her anticoagulation trend, bleeding episode, and prior cardiac and pulmonary findings should guide risk-benefit reassessment of her management.
Problem 1. Anticoagulation control and left atrial thrombus
Problem 2. End-stage renal disease and AV shunt care
Problem 3. Cardiopulmonary comorbidities: Pulmonary hypertension and COPD
Problem 4. Anemia of chronic disease
Problem 5. Electrolyte and metabolic status
The patient is a 56-year-old woman with refractory atrial fibrillation complicated by a visible left atrial thrombus, and is on warfarin anticoagulation (daily dose 6 mg). Recent INR and coagulation profiles show a progressive rise in INR to 3.47 on 2025-08-06, exceeding the typical therapeutic range. The patient also has end-stage renal disease (on hemodialysis) and previously experienced minor AV shunt site oozing. Coagulation parameters including PT and APTT are elevated. While anticoagulation is clearly warranted due to the thrombus, the current supratherapeutic range suggests an increased bleeding risk, warranting urgent reassessment and adjustment.
Problem 1. Supratherapeutic INR under warfarin therapy
Problem 2. Elevated APTT alongside supratherapeutic INR
Summary Recommendation Snapshot
[exam finding]
[MedRec]
[Subjective]
Contact attempt and education - Phone call did not reach the patient; message left with family - Requested strict adherence to the current prescriptions and follow-up plans - Provided key medication precautions and monitoring points - Reported symptoms from recent notes - Back pain present - No current chest pain reported in OPD notes; prior syncope on 2025-08-03 with subsequent admission and workup (POMR Cardiology 2025-08-04~08-09)
Medication history and recent changes - New/renewed outpatient prescriptions on 2025-09-24 (Cardiology; Prescription x3 = 84 days) - Bokey (aspirin 100mg) 1# QD - Concor (bisoprolol 5mg) 1# QD - Through (sennoside 12mg) 2# HS - Linicor (niacin 500mg, lovastatin 20mg) 1# BID - Feburic FC (febuxostat 80mg) 0.5# QD - Trajenta (linagliptin 5mg) 1# QD - Same day additional prescriptions (Nephrology 2025-09-24; Prescription x3 = 84 days) - Pentop (pentoxifylline 400mg) 1# QD - Ulstop FC (famotidine 20mg) 1# QD - Prior active discharge/OPD medications to reconcile - Blopress (candesartan 8mg) 1# QD; Concor (bisoprolol 5mg) 1# QD; Spiron (spironolactone 25mg) 1# QD; Forxiga (dapagliflozin 10mg) 1# QDAC; Dexilant (dexlansoprazole 60mg) 1# QD; Uretropin (furosemide 40mg) 0.5# PRNQOD if weight gain >0.5kg; MgO (magnesium oxide 250mg) 1# BID; Promeran (metoclopramide 3.84mg) 1# TIDAC; Smecta (diosmectite 3g) PRN; Through (sennoside) 2# HS (Discharge 2025-08-09) - Kentamin (B1 50mg, B6 50mg, B12 500mcg) 1# TID; Folacin (folic acid 5mg) 1# QD (Hemato-Oncology 2025-09-24)
[Objective]
Key clinical data and risk profile - Cardiac structure/function - Echo: LVEF 37%, grade 3 restrictive filling, LA/LV dilation, moderate MR/AR/TR, PASP ~39 mmHg, pleural effusions, IVC 20mm with <50% collapse (Echo 2025-08-04) - Ischemia and coronaries - SPECT: multiterritory reversible ischemia with post-stress LV dilation (high-risk finding) (SPECT 2025-08-06) - CAG: patent LAD stent; RCA-P 62%, LCX-D 44%; SYNTAX 4; no interval change vs 2024 (CAG 2025-08-07) - Rhythm - Holter: PVC burden 11%, baseline QT prolongation; 10 short-run AT, no long pause (Holter 2025-08-05) - Hematology and chemistry (most recent) - Hgb 9.8 g/dL, WBC 3.81 x10^3/uL, PLT 149 x10^3/uL (CBC 2025-09-24) - Ferritin 243.7 ng/mL; Fe 53 ug/dL; TIBC 203 ug/dL (2025-09-24) - Creatinine 1.01 mg/dL, eGFR 56.2 mL/min/1.73m^2 (2025-09-24) - Glucose 199 mg/dL (serum) (2025-09-24) - CK 323 U/L (2025-09-24) - Prior electrolytes notable for hypokalemia 2.6–3.2 mmol/L and hypomagnesemia 1.1 mg/dL (2025-08-03 to 2025-08-07) - Lipids and glycemic control history - LDL-C 159 mg/dL (2025-07-30); HbA1c 5.4% (2025-07-30), 6.3% (2025-02-10) - GI bleeding screen - Stool OB positive 2+ (2025-04-22), 1+ (2025-06-21), negative (2025-08-06)
Drug therapy problem list (data-linked) - Secondary prevention not at LDL goal on Linicor (niacin/lovastatin) with CK elevation and myalgia risk (CK 323 U/L 2025-09-24; LDL-C 159 mg/dL 2025-07-30) - HFrEF on partial GDMT: low-dose ARB, on beta-blocker, MRA, SGLT2; ARNI not initiated (Echo 2025-08-04; Rx 2025-08-09) - Arrhythmic risk with frequent PVCs and prior QT prolongation; contributing meds and electrolytes include metoclopramide and sennoside plus intermittent loop diuretic (Holter 2025-08-05; K/Mg lows 2025-08-03~08-07) - Polypharmacy and potential duplications/interactions - Dual acid suppression risk if Dexilant continued alongside Ulstop (famotidine) (Rx 2025-08-09 vs 2025-09-24) - Pentop (pentoxifylline) adds bleeding risk when combined with aspirin; unclear current indication - Kentamin provides B6 150 mg/day chronically, neuropathy risk; B12/folate levels previously supranormal (B12 2138 pg/mL; Folate >46.4 ng/mL on 2025-08-07) - CKD G3a post-AKI; dehydration and nephrotoxic risks with SGLT2 and PRN loop use (Cr/eGFR 2025-09-24; AKI 2025-04-21) - Anemia with multi-lineage cytopenias; ongoing evaluation for ACD/CKD vs MDS vs intermittent GI loss (CBC/iron 2025-09-24; stool OB history)
[Assessment]
Therapeutic priorities and rationale - ASCVD secondary prevention - LDL far above target for post-MI/HFrEF patient; niacin/statin combo increases myopathy risk and glycemic worsening without proven outcome benefit; CK already elevated with back pain (LDL-C 159 mg/dL 2025-07-30; CK 323 U/L 2025-09-24) - Heart failure optimization - ARNI transition or RAAS uptitration indicated if BP/renal status allow; volume and electrolyte plans needed to prevent decompensation (Echo 2025-08-04; prior very high NT-proBNP 29368.5 pg/mL 2025-08-03) - Arrhythmia mitigation - PVC burden 11% and QT prolongation call for removal of QT-prolonging meds and strict K/Mg control; PVC reduction may improve EF (Holter 2025-08-05) - Medication safety and simplification - Possible duplicate acid suppression (Dexilant vs Ulstop); metoclopramide QT/neurologic risk; chronic stimulant laxative contributing to hypokalemia; high-dose B6 neuropathy risk; pentoxifylline bleeding risk with uncertain benefit - CKD and anemia integration - Renal function improved but remains CKD G3a; maintain kidney-protective regimen and sick-day rules; anemia workup ongoing with consideration of ACD/CKD vs MDS vs GI loss
[Plan / Recommendation]
Immediate patient/caregiver instructions left (2025-09-24) - Adherence and organization - Take medicines exactly as prescribed; do not stop or add medicines without checking with the clinic - Use a weekly pill box and a medication list taped to the refrigerator; bring pill bottles or photos to each visit - Daily monitoring and call thresholds - Weigh every morning after urinating; call if weight rises ≥1 kg in 24 hours or ≥2 kg in a week - Check blood pressure and pulse twice daily for the next 2 weeks; call if SBP <90 mmHg with dizziness or pulse <50/min with symptoms - Watch for chest pressure, severe shortness of breath, fainting, black stools, or unusual bleeding; go to emergency care if severe or persistent - Sick-day rules to protect kidneys and heart - If vomiting, diarrhea, fever, or poor intake: hold Forxiga (dapagliflozin) and Uretropin (furosemide); sip fluids; restart when eating/drinking normally; call clinic if not improved within 24–48 hours
Medication-specific counseling and safety adjustments for prescriber review - Lipid therapy - Recommend stop Linicor (niacin/lovastatin) due to CK elevation and limited outcome benefit; start Crestor (rosuvastatin) 20 mg QD or Lipitor (atorvastatin) 40 mg QD, check CK in 1–2 weeks and lipids in 4–6 weeks (LDL goal: aggressive secondary prevention) - Heart failure core meds - Consider transition from Blopress (candesartan) to Entresto (sacubitril/valsartan) if BP and renal function allow; otherwise uptitrate candesartan toward target; continue Concor (bisoprolol), Spiron (spironolactone), Forxiga (dapagliflozin) - Convert PRN Uretropin (furosemide) to a written sliding-scale plan tied to daily weights and symptoms; set K goal 4.0–4.5 mmol/L, Mg >2.0 mg/dL - Arrhythmia risk reduction - Discontinue Promeran (metoclopramide) unless short-term compelling need; avoid other QT-prolonging agents - Reduce Through (sennoside) to lowest effective dose; prefer stool softener or osmotic laxative to limit K/Mg losses - Intensify electrolyte repletion: increase MgO (e.g., to 400–800 mg/day in divided doses) and add oral K supplementation per labs; recheck K/Mg within 1 week after dose changes - Repeat 24-hr Holter after electrolyte correction and GDMT optimization - Gastroprotection and duplication check - Reconcile acid suppression: if Dexilant (dexlansoprazole) is still used, avoid duplicate Ulstop (famotidine) unless specifically indicated; prefer single-agent PPI with aspirin history and prior positive stool OB (2025-04-22, 2025-06-21, negative 2025-08-06) - Antiplatelet and bleeding risk - Continue Bokey (aspirin) 100mg QD with gastroprotection; reassess Pentop (pentoxifylline) utility vs bleeding risk when combined with aspirin; consider deprescribing if no clear indication - Gout management - Feburic FC (febuxostat): urate at goal historically; given CAD/HFrEF, discuss switch to Zyloprim (allopurinol) with renal-adjusted titration unless prior intolerance - Diabetes integration - Continue Forxiga (dapagliflozin) for HF/renal benefit; with glucose 199 mg/dL (2025-09-24), check HbA1c now; consider adding Trajenta (linagliptin) 5mg QD if A1c above target and no pancreatitis recurrence concerns - Vitamins and supplements - Stop high-dose B6 exposure from Kentamin if no clear indication; maintain only needed B12/folate based on labs; avoid non-prescribed supplements that may interact
Monitoring and follow-up labs - In 1 week (or sooner if symptomatic) - BMP (Na/K/CO2/Cr), Mg, CK if muscle pain persists - In 2–4 weeks - Lipid panel after statin change; HbA1c; CBC with smear, reticulocyte count; iron panel with CRP; TSH - In 4–12 weeks - Repeat Echo about 3 months after GDMT changes (Echo baseline 2025-08-04); consider FFR/iFR for RCA/LCX if symptoms or evidence of ischemia persist (SPECT 2025-08-06; CAG 2025-08-07)
Coordination items for the care team - Medication reconciliation across services to remove duplications and clarify active list (Dexilant vs Ulstop; Pentop indication; PRN vs scheduled diuretics) - Discuss ARNI initiation, lipid regimen change, and pentoxifylline deprescribing at next Cardiology OPD - Hematology to continue anemia/cytopenia workup; GI to consider endoscopy if anemia persists or stool OB re-positives
Education highlights for family (simple reminders) - Keep a daily log of weight, BP, pulse, blood sugar (if checked), and symptoms; bring to clinic - Bring all pill bottles or photos and the medication list to each visit - Seek urgent care for chest pain >5 minutes, severe shortness of breath, fainting, or black stools
Key insights / summary
Problem 1. High-risk myocardial ischemia with discordant tests (SPECT high-risk vs non-obstructive CAG)
Problem 2. Heart failure with reduced EF (LVEF 37%) and grade 3 restrictive diastolic dysfunction
Problem 3. Ventricular ectopy (PVC burden 11%), baseline QT prolongation, and electrolyte instability
Problem 4. Anemia (macrocytic → normocytic), leukopenia, borderline thrombocytopenia; r/o MDS vs CKD/inflammation vs intermittent GI loss
Problem 5. Atherosclerotic risk and dyslipidemia: LDL far from goal; CK elevation with myalgias on niacin/lovastatin
Problem 6. CKD G3a after severe AKI in 2025-04; renal and cardiorenal risk
Problem 7. Valvular regurgitations (moderate MR/AR/TR) with mild pulmonary hypertension
Problem 8. Type 2 diabetes with recent hyperglycemia; cardiometabolic integration
Problem 9. Gout; urate control vs febuxostat safety in CAD/HF
Problem 10. Prior acute pancreatitis and intermittent GI bleeding risk under antiplatelet therapy
Problem 11. Medication safety and de-prescribing priorities
Problem 12. Syncope (index event 2025-08-03) – multifactorial evaluation
Data gaps / follow-ups needed
Why MDS (myelodysplastic syndrome) is on the table
Key alternative diagnoses to consider (with pro/con from this case and how to differentiate)
What to do next (focused, high-yield workup to confirm/deny MDS and rule in/out alternatives)
Bottom line
Key Things to Watch For
Information to Bring to Your Next Appointment
Questions to Ask Your Doctor
Helpful Daily Habits
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Key insights / summary
Problem 1. Esophageal squamous cell carcinoma, cT3N0M0, stage IIB, on definitive CCRT (PF4) + RT
Problem 2. Hypoglycemia during admission (jejunostomy feeding; single very low FS)
Problem 3. Renal protection under cisplatin; electrolytes (K/Mg) and hydration
Problem 4. Hematologic tolerance / myelosuppression risk
Problem 5. Nutrition and weight loss; jejunostomy support
Problem 6. HBV reactivation prophylaxis during CCRT
Problem 7. Cisplatin ototoxicity risk with baseline sensorineural hearing loss
Problem 8. Gastrointestinal toxicities (nausea/diarrhea; mucositis risk)
Problem 9. Incidental hepatic and prostatic findings under surveillance
Problem 10. Cardiopulmonary fitness and peri-treatment safety
Medications in use (selected, with format rule)
Follow-up checkpoints
[exam finding]
[lab data]
2025-08-27 SCC (NM) 13.5 ng/mL
2025-08-27 HBsAg (NM) Negative
2025-08-27 HBsAg Value (NM) 0.353
2025-08-27 Anti-HBc (NM) Positive
2025-08-27 Anti-HBc Value (NM) 0.019
2025-08-27 Anti-HBs (NM) Positive
2025-08-27 Anti-HBs value (NM) >1000 mIU/mL
2025-08-27 Anti-HCV (NM) Negative
2025-08-27 Anti-HCV Value (NM) 0.041
[exam finding]
[MedRec]
[surgical operation]
Key insights / summary
Problem 1. Acute upper aerodigestive bleeding due to tongue/tongue-base SCC
Problem 2. Airway compromise risk and dysphagia/aspiration
Problem 3. Oncologic disease control strategy (cT3N2cM0 oral tongue/base SCC; surgery declined)
Problem 4. Severe unintentional weight loss / cancer-related malnutrition
Problem 5. Anemia due to ongoing tumor bleeding
Problem 6. Possible superimposed regional infection/lymphadenitis
Problem 7. Medication review and supportive care
Problem 8. HBV serology in context of future systemic therapy
Problem 9. Thrombosis prophylaxis and device care
Problem 10. Electrolytes, renal/hepatic function monitoring
[exam finding]
[MedRec]
[lab data]
2025-07-31 VZV IgM Negative Index
2025-07-31 VZV IgM Value 0.1 Ratio
2025-07-28 CMV viral load assay Target Not Detected IU/mL
2025-07-25 HBV DNA PCR (quan) <10 IU/mL
2025-07-23 CD45+Total leukocyte 258533 /uL
2025-07-23 %CD34+ 2.21 %
2025-07-23 CD34+ Count 5698 /uL
2025-07-23 CD45+Total leukocyte 14266 /uL
2025-07-23 %CD34+ 0.94 %
2025-07-23 CD34+ Count 134 /uL
2025-07-22 CD45+Total leukocyte 119572 /uL
2025-07-22 %CD34+ 3.88 %
2025-07-22 CD34+ Count 4645 /uL
2025-07-22 CD45+Total leukocyte 4748 /uL
2025-07-22 %CD34+ 1.88 %
2025-07-22 CD34+ Count 89 /uL
2025-06-24 Covid PCR Detected
2025-06-02 EB VCA IgG Positive Ratio
2025-06-02 EB VCA IgG Value 4.2 Ratio
2025-05-30 VZV IgG Positive mIU/mL
2025-05-30 VZV G Value 1492 mIU/mL
2025-05-29 HBsAg (NM) Positive
2025-05-29 HBsAg Value (NM) 1796
2025-05-29 Anti-HBc (NM) Positive
2025-05-29 Anti-HBc Value (NM) 0.009
2025-05-29 Anti-HBs (NM) Negative
2025-05-29 Anti-HBs value (NM) <2.0 mIU/mL
2025-05-29 Anti-HCV (NM) Negative
2025-05-29 Anti-HCV Value (NM) 0.035
2025-05-29 CMV IgG Reactive
2025-05-29 CMV IgG Value 107.3 AU/mL
2025-05-29 CMV IgM Nonreactive
2025-05-29 CMV IgM Value 0.24 Index
2025-05-29 Anti HTLV I/II Nonreactive
2025-05-29 Anti HTLV I/II Value 0.08 S/CO
2025-05-29 EB VCA IgM Negative Index
2025-05-29 EB VCA IgM Value 0.1 Index
2025-05-29 HIV Ab-EIA Nonreactive
2025-05-29 Anti-HIV Value 0.08 S/CO
2023-10-20 HBV DNA PCR (quan) 41500 IU/mL
[exam finding]
[MedRec]
| Day | -7 | -6 | -5 | -4 | -3 | -2 | -1 | 0 | +1 | +2 |
|---|---|---|---|---|---|---|---|---|---|---|
| Date | 8/27 | 8/28 | 8/29 | 8/30 | 8/31 | 9/01 | 9/02 | 9/03 | 9/04 | 9/05 |
| Weekday | Wed | Thu | Fri | Sat | Sun | Mon | Tue | Wed | Thu | Fri |
| Rituximab | V | |||||||||
| Carmustine | V | |||||||||
| Etoposide | V | V | V | V | ||||||
| Cytarabine | VV | VV | VV | VV | ||||||
| Melphalan | V | |||||||||
| PBSC | V | V | ||||||||
| GCSF | V | |||||||||
| Basic IVF | 1000 | 1000 | 1000 | 1000 | 1000 | 1500 | 1500 | 1500 | 1500 | 1000 |
| Premed | Dexa, Vena, Akynzeo, Scanol | Dexa Vena | Dexa, Vena, Ondansetron | Ondansetron | Ondansetron | Akynzeo | Dexa, Vena | Solu-cortef, Vena, Ondansetron, Scanol | Solu-cortef, Vena, Ondansetron, Scanol | |
| Betame eye | V | V | V | V | V | |||||
| Cryotherapy | V | |||||||||
| Cravit | V | V | V | V | V | V | V | V | V | V |
| Fluconazole | V | V | V | V | V | V | V | V | V | V |
| Baktar | V | V | V | V | V | V | V | V | V | V |
| Valacyclovir | V | V | V | V | V | V | V | V | V | V |
| PPI | V | V | V | V | V | V | V | V | V | V |
| Entecavir | V | V | V | V | V | V | V | V | V | V |
[consultation]
[surgical operation]
[immunochemotherapy]
Key insight / summary
Problem 1. Post-ASCT engraftment status
Problem 2. Thrombocytopenia and chemotherapy-related anemia
Problem 3. Infection risk, prophylaxis and antimicrobial stewardship
Problem 4. Pulmonary disease (COPD/emphysema) with intermittent hypoxemia
Problem 5. Renal, hepatic function and electrolyte stewardship / drug safety
Problem 6. HBV reactivation prevention after anti-CD20 exposure
Problem 7. GI/mucositis prophylaxis and bowel symptoms
Overall
(SOAP; not for post)
[Subjective]
Post-ASCT day +15 today (conditioning R-BEAM D-7 to D-1: rituximab 2025-08-27, carmustine 2025-08-28, etoposide/cytarabine 2025-08-29–2025-09-01, melphalan 2025-09-02; PBSC 2025-09-03 and 2025-09-04).
[Objective]
Transplant/engraftment status
Vital signs (selected)
Labs and trends
Imaging
Anti-infective course (key agents/dates)
Other active medications (selected symptomatic/supportive)
[Assessment]
Post-ASCT day +15, engraftment achieved; antimicrobial stewardship and supportive care optimization are now the priorities.
[Plan / Recommendation]
Transplant/engraftment
Antimicrobial stewardship
Cytopenias
HBV management
Pulmonary/COPD and oxygenation
GI/mucositis and supportive care
Analgesia and antipyretic
Electrolyte and renal targets
Vaccination and long-term planning
Monitoring and follow-up
Overall, medication use is appropriate for day +15 post-ASCT with recovery; key opportunities are stopping G-CSF now that engraftment is established and continuing de-escalated anti-infective strategy while maintaining antiviral/PJP prophylaxis and HBV suppression, with vigilant monitoring of cytopenias and pulmonary status.
Key insight / summary
Problem 1. Post-ASCT day +6 with expected severe neutropenia (ANC=0) and early pulmonary changes
Problem 2. Hematologic recovery management after R-BEAM (pancytopenia)
Problem 3. Mucositis and gastrointestinal supportive care
Problem 4. Pulmonary status in a patient with baseline COPD/emphysema
Problem 5. Organ function monitoring and drug stewardship
Problem 6. Lines, analgesia, and general supportive care
Overall plan checkpoints for the next 48–72 hours (through day +9)
Key insight/summary
Note for summary (not for post) - Comment on change of prophylaxis vs empiric/therapeutic anti-infective strategy
Problem 1. Post-ASCT day +2 cytopenias with infection risk
Note for problem 1 (not for post)
Here’s the bottom line up front: using Granocyte (lenograstim) and Filgrastim (filgrastim) together offers no added clinical benefit and is not recommended. Both are granulocyte colony-stimulating factors (G-CSFs) that act on the same receptor and produce the same pharmacodynamic effect; high-quality guidelines and comparative studies support using a single G-CSF agent, not a combination. 13
What they are
Evidence on efficacy and safety (head-to-head and class data)
Why combination use is not reasonable
Practical, evidence-aligned approach for this patient (post-autologous PBSCT)
In short, stick with a single G-CSF (either lenograstim or filgrastim) dosed appropriately. Combining them is unsupported by evidence or guidelines and only adds cost and complexity without improving outcomes. 1
Ref:
Note from Nurse Practitioner (not for post) - Using Granocyte (lenograstim) vs Filgrastim (filgrastim) Together is based on consideration of patient body weight; Comparison of Using Granocyte (lenograstim) vs Filgrastim (filgrastim) Together
Note for problem 1 (not for post)
Problem 2. Mucositis risk and early symptoms post-melphalan
Problem 3. Renal function and fluid-electrolyte stewardship
Problem 4. Pulmonary status with prior COPD/emphysema and peri-transplant oxygenation
Problem 5. HBV carrier on anti-CD20 exposure and peri-transplant reactivation prophylaxis
Problem 6. Thrombosis/bleeding, mucosal care, and line management
Problem 7. Cardiometabolic monitoring under chemotherapy
Overall care priorities today (2025-09-05)
The patient, a 62-year-old man with recurrent follicular lymphoma undergoing R-BEAM conditioning for autologous stem cell transplant, is in the immediate pre-infusion period (Day -1 melphalan planned). His condition reflects expected toxicities of intensive chemotherapy, but careful monitoring and optimization are essential.
What to improve
Overall, the patient remains clinically stable, with controlled fluid status, preserved renal and hepatic function, and adequate infection prophylaxis. The most critical point is careful supportive management over the next 2–3 weeks until engraftment, particularly monitoring pulmonary status, cytopenia-related risks, and infection.
The patient is a 62-year-old man with recurrent follicular lymphoma, grade 3A, FLIPI 2, admitted on 2025-08-25 for autologous stem cell transplantation with R-BEAM conditioning (D-7 Rituximab on 2025-08-27, D-6 Carmustine on 2025-08-28, D-5 Etoposide/Cytarabine on 2025-08-29). He has a history of chronic hepatitis B (on Baraclude (entecavir)) and BPH (on Harnalidge OCAS (tamsulosin)). On 2025-08-28, he developed dyspnea, tachycardia, desaturation with basal rales, and increased lung markings (CXR 2025-08-28, 2025-08-29) suggesting fluid overload or pulmonary involvement. Diuretics (Urex (furosemide)) and bronchodilator (Atrovent) were started. Renal function shows mild fluctuations (Cr 0.87 mg/dL on 2025-08-25 → 1.16 mg/dL on 2025-08-29), BUN trending up (24 → 28 mg/dL), eGFR declined to 67.81. Hematology shows WBC 11.4k/µL with neutrophilia 88.5%, Hb 11.1 g/dL, platelets ~117k (2025-08-29). Infection markers remain low (CRP <0.1 mg/dL, PCT 0.02 ng/mL on 2025-08-28). Overall, the patient is in early conditioning phase with evolving pulmonary and renal concerns.
Problem 1. Pulmonary dysfunction with dyspnea, desaturation, and possible effusion
Problem 2. Renal function fluctuation under conditioning regimen (not posted)
Problem 3. Hematologic profile and cytopenia risk (not posted)
Problem 4. Infection risk under immunosuppression and devices (not posted)
Problem 5. Hepatitis B reactivation risk under Rituximab and ASCT (not posted)
Problem 6. Electrolyte and metabolic stability (not posted)
The patient is a 62-year-old male with recurrent follicular lymphoma (grade 3A, FLIPI 2, intermediate risk) currently admitted for autologous stem cell transplantation with R-BEAM conditioning (protocol start planned on 2025-08-27). He has history of HBV carrier (on Baraclude (entecavir)) and BPH (on Harnalidge OCAS (tamsulosin)). Recent labs on 2025-08-25 show mild anemia (Hb 10.8 g/dL), thrombocytopenia (115k/µL), and stable renal (Cr 0.87 mg/dL, eGFR 94.5) and hepatic function (AST 17 U/L, ALT 16 U/L). Cardiac function is preserved (LVEF 82% on 2025-04-21 echo). Pulmonary function test (2025-07-30) suggests COPD with emphysematous features but reversible obstruction. Vitals remain stable, with mild intermittent low SpO2 (94%). Current prophylactic regimen includes levofloxacin, fluconazole, valacyclovir, Morcasin (sulfamethoxazole/trimethoprim), and supportive electrolytes. Conditioning-related risks include mucositis, cytopenia, infections, pulmonary/cardiac toxicity, and HBV reactivation.
Problem 1. Recurrent Follicular Lymphoma, grade 3A, FLIPI 2, preparing for ASCT
Problem 2. Hematologic status (anemia and thrombocytopenia pre-ASCT)
Problem 3. Pulmonary function: COPD/emphysema risk during conditioning (not posted)
Problem 4. Chronic Hepatitis B infection under immunosuppression risk
Problem 5. Electrolyte and metabolic status (risk during R-BEAM) (not posted)
[HSCT Recipients - Pet Exposure - Feline Contact] (not posted)
CLINICAL RECOMMENDATION
Pet ownership (cats) is NOT RECOMMENDED for HSCT patients during immunocompromised periods.
RISK ASSESSMENT
High-Risk Period
Infectious Risks Associated with Feline Exposure
Transmission Routes
CLINICAL CONSIDERATIONS
Patient Factors Requiring Assessment
Monitoring Parameters
ALTERNATIVE RECOMMENDATIONS
If Pet Already in Household
Environmental Modifications
PATIENT COUNSELING POINTS
[HSCT Recipients - Pet Exposure - Feline Contact]
Subject: Pet Ownership Post-Hematopoietic Stem Cell Transplant (HSCT)
Recommendation: Discourage cat ownership, especially during the initial recovery phase (first year post-HSCT).
Rationale:
Counseling Points (patient’s daughter already owns a cat):
Conclusion: The safest course of action is to have the cat rehomed or cared for by a family member for at least the first year. Patient safety is the top priority.
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[Subjective]
Chief concerns and context
Breast cancer history and current therapy (reference for indication)
Comorbidities and pertinent history
Medication list relevant to counseling
[Objective]
Vital/labs/imaging pertinent to risk stratification
Risk facts from pharmacovigilance (for documentation of counseling content)
[Assessment]
Tamoxifen appropriateness and risk–benefit
Potential improvements (care optimization)
[Plan / Recommendation]
Monitoring and safety plan
Hot flash management (tiered, nonhormonal)
Drug–drug and drug–condition precautions
Follow-up and documentation
Patient education delivered today
Key insights / summary
Problem 1. Right-breast ER+/PR+ grade 3 DCIS, pTis, s/p partial mastectomy with negative margins and adjuvant RT; choice and duration of adjuvant endocrine therapy
Problem 2. Post-RT surveillance and recurrence monitoring
Problem 3. Bone scan abnormalities likely degenerative, low likelihood of metastasis from pure DCIS
Problem 4. Gynecologic/endometrial risk on tamoxifen
Problem 5. Fatty liver and fatty pancreas, currently normal liver enzymes
Problem 6. Bone health planning if transitioning to an aromatase inhibitor
Problem 7. Left nephrolithiasis, 0.87 cm, asymptomatic
Problem 8. Hypertension, long-standing
Problem 9. Use of tumor markers for surveillance
Problem 10. General survivorship and preventive care
Breast cancer treatment alignment with guidelines
[Reminders for Long-Term Use of Nolvadex (tamoxifen)]
General monitoring
Key side effects and what to do
Routine follow-up
Lifestyle reminders
Medication safety
[Instructions for the Patient and Caregiver]
Key Things to Watch For
Information to Bring to Your Next Appointment
Questions to Ask Your Doctor
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[note]
Systemic therapy regimens for adjuvant and neoadjuvant treatment of urothelial cancer: Gemcitabine and cisplatin - 2025-09-17 - https://www.uptodate.com/contents/image?imageKey=ONC%2F128074
Systemic therapy regimens for urothelial carcinoma: MVAC - 2025-09-17 - https://www.uptodate.com/contents/image?imageKey=ONC%2F64950
[Subjective]
Follow-up with the patient’s daughter (2025-09-17)
[Objective]
Cancer and treatments
Kidney function and urine studies
eGFR/creatinine trend: 121.21 (2025-06-30, 24-hr CCr estimate) → 106.86 (2025-07-14) → 77.06 (2025-08-04) → 58.34 (2025-08-25) → 51.60 (2025-09-02) → 50.53 (2025-09-15).
UA pattern: recurrent hematuria and pyuria; examples
UTI management: Keflex (cephalexin) empiric started 2025-09-15; urine culture planned.
Hematology and transfusion
HBV prophylaxis and liver tests
Chronic meds (current/recent per chart)
[Assessment]
Medication therapy assessment and issues prioritized
[Plan / Recommendation]
Monitoring and documentation at home (reinforce with caregiver)
Medication-specific actions
Laboratory and test follow-up (coordinate scheduling)
Perioperative and long-term planning
Education and caregiver support
Clinic items to address at next visit
[DDMVAC regimen]
The NCCN guidelines (2025-03-25) recommend DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, cisplatin with G-CSF support) as the preferred neoadjuvant regimen because randomized trials and meta-analyses demonstrate higher efficacy and improved survival compared with older schedules. However, in practice, many patients are instead given Gemcitabine + Cisplatin (GC). The main reasons in this patient’s case are:
Age and frailty: The patient is 78 years old, with ECOG 1 but clear comorbidities (hypertension, hyperlipidemia, dementia CDR 2, MMSE 5 on 2025-07-25). DDMVAC is more intensive, with higher risk of febrile neutropenia, mucositis, and cardiotoxicity. GC is generally better tolerated in elderly and frail patients.
Bone marrow reserve: Before cycle 4 (2025-09-15), labs showed Hb 7.4 g/dL, ANC 1498, WBC 3.12 x10^3/uL, requiring transfusion and antibiotics for pyuria. This shows already significant myelosuppression. DDMVAC is much more myelotoxic compared with GC, so safety becomes a limiting factor.
Renal function: The patient’s eGFR has declined from >100 mL/min/1.73m^2 (2025-07-14) to ~50 mL/min/1.73m^2 (2025-09-15). Cisplatin can still be used with caution, but DDMVAC requires robust renal clearance. GC is considered a more acceptable cisplatin-based regimen in borderline renal function.
Cardiac considerations: Echo (2024-07-19) showed mild MR/TR/PR and impaired LV relaxation. Anthracyclines (doxorubicin in DDMVAC) add cardiotoxicity risk. In a patient with hypertensive heart disease and aging myocardium, avoiding anthracyclines is reasonable.
Practicality and adherence: GC is given on a simpler schedule (21-day cycles, day 1 and day 8 dosing), with fewer hospitalizations. DDMVAC requires more frequent monitoring, growth factor support, and inpatient resources, which may not be realistic given the family’s already high caregiving burden.
Summary:
Key insights / summary
Problem 1. Muscle-invasive bladder cancer, neoadjuvant management and definitive plan
Problem 2. Hematologic toxicity (anemia, neutropenia risk) related to chemotherapy and chronic disease
Problem 3. Renal function risk under cisplatin
Problem 4. Urinary tract infection and hematuria
Problem 5. Hepatitis B reactivation risk under chemotherapy
Problem 6. Cognitive impairment and geriatric-oncology considerations
Problem 7. Cardiovascular status under oncologic therapy
Problem 8. Electrolyte and metabolic monitoring under cisplatin
Problem 9. Surgical candidacy and postoperative systemic therapy planning
Problem 10. Port-A and infection prophylaxis
Medications referenced (current/recent):
Notes tying to NCCN guidance (2025):
[Comprehensive Home Instructions for the Patient and Caregiver]
Key Things to Watch For
Information to Bring to Your Next Appointment
Questions to Ask Your Doctor
Simple Daily Routine (optional checklist)
Safety Reminders
Contact Information to Keep Handy
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[Subjective]
Follow-up after chemotherapy - telephone call with her son - Reports constipation has improved compared with prior cycles. - Reports peripheral neuropathy symptoms (numbness/tingling) persist without relief. - Counseled to help the patient track and describe neuropathy pattern (onset after vincristine, distribution in hands/feet, intensity, interference with ADLs, any weakness/falls) at the next visit. - Advised to discuss with the oncologist potential regimen adjustment (vincristine) and consideration of symptom-directed therapy such as Cymbalta (duloxetine).
Recent symptom history (context) - 2025-08-11 numbness noted after cycle 3; 2025-07-14 constipation and fatigue documented; ongoing fatigue through 2025-09-15. - No current fever, chills, or new GI alarm symptoms reported in the call.
[Objective]
Oncologic diagnosis and treatments - DLBCL, GCB subtype; extensive extranodal disease at baseline (PET 2025-05-22; Pathology 2025-05-26). - Immunochemotherapy (R-miniCHOP): - Cycle 1: rituximab + cyclophosphamide + doxorubicin + vincristine + prednisolone on 2025-05-28 with Akynzeo (netupitant/palonosetron), dexamethasone premedications. - Cycle 2: 2025-06-30 (same backbone and premedications). - Cycle 3: 2025-08-01 (same backbone and premedications). - Cycle 4: 2025-09-08 (same backbone and premedications). - Interim response: PET on 2025-09-12 shows many baseline hypermetabolic lesions disappeared; residual uptake less evident at sinonasal/maxillary/thyroid sites; physiologic uptake in kidneys/ureters/colon.
Laboratory trends (most recent key values) - 2025-09-08: WBC 5.60×10^3/uL; neutrophils 75.9%; HGB 10.5 g/dL; PLT 242×10^3/uL; LDH 161 U/L; Na 138 mmol/L; K 4.4 mmol/L; BUN 35 mg/dL; Creatinine 0.85 mg/dL (eGFR 70.69 mL/min/1.73 m^2); AST/ALT 27/29 U/L; CRP 0.33 mg/dL. - Prior peaks/toughs: LDH 441 U/L (2025-06-02) improved; bilirubin total 5.03 mg/dL (2025-05-29) normalized by 2025-08-01; WBC nadir 1.78×10^3/uL (2025-06-09).
Current and recent medications (selected) - Sevikar HCT (olmesartan/amlodipine/hydrochlorothiazide) 1 tab QD (ongoing). - Takepron (lansoprazole) 30 mg QDAC (ongoing). - MgO (magnesium oxide) 250 mg TID; Through (sennoside) HS; Mosapin (mosapride citrate) 5 mg TID (bowel regimen). - Eurodin (estazolam) 2 mg HS (sleep). - Acetal (acetaminophen) 500 mg Q6H PRN pain. - Vemlidy (tenofovir alafenamide) 25 mg QD (HBV prophylaxis). - Akynzeo (netupitant/palonosetron) with each cycle; dexamethasone and diphenhydramine premedications. - Granocyte (lenograstim) 250 mcg SC daily ×4 days started 2025-09-15 for secondary prophylaxis.
Cardio-renal/hepatic context - Echocardiography 2025-05-23: normal LVEF by M-mode 75%, grade II diastolic dysfunction. - Renal function preserved (Creatinine 0.85 mg/dL, eGFR 70.69 mL/min/1.73 m^2, 2025-09-08) with mild azotemia (BUN 35 mg/dL). - LFTs within normal on 2025-09-08; prior cholestasis resolved.
[Assessment]
Chemotherapy-induced peripheral neuropathy (CIPN), persistent; constipation improved - Vincristine temporal association and symptom profile suggest CIPN (likely CTCAE grade 1–2 given persistent sensory symptoms without reported motor deficits or ADL-limiting pain). - Risk modifiers: concurrent NK1 antagonist Akynzeo (netupitant/palonosetron) each cycle can moderately inhibit CYP3A and may increase vinca neurotoxicity; cumulative vincristine exposure across 4 cycles may contribute. - Hepatic function is currently normal (AST/ALT 27/29 U/L, 2025-09-08), so impaired clearance is less likely now; prior cholestasis has resolved. - Constipation has improved on stimulant prokinetic regimen (sennoside + mosapride) and is likely multifactorial (vincristine autonomic neuropathy, 5-HT3 antagonist effect, ondansetron/palonosetron class, reduced intake/activity around chemo days).
Suitability of duloxetine and alternative options - Cymbalta (duloxetine) is reasonable for painful CIPN; benefits typically emerge by 2–6 weeks. Safety considerations in this patient: - Blood pressure: may increase slightly; she is on Sevikar HCT with generally acceptable BP control. - Hepatic: avoid if significant hepatic dysfunction; current LFTs normal but continue monitoring due to prior cholestasis. - Electrolytes: SIADH/hyponatremia risk in older adults; Na 138 mmol/L (2025-09-08) is acceptable; monitor. - Drug interactions: duloxetine (CYP2D6 inhibitor) has minimal impact on current regimen; additive CNS sedation possible with Eurodin (estazolam) HS.
Need to review antiemetic backbone and vinca dosing for neurotoxicity mitigation - Ongoing use of Akynzeo (netupitant/palonosetron) provides strong antiemesis but may increase vincristine exposure; if neuropathy progresses, a NK1-sparing antiemetic strategy (e.g., palonosetron + dexamethasone ± Zyprexa (olanzapine)) could be weighed against emesis risk. - If neuropathy grades up (≥2), dose reduction or omission of Oncovin (vincristine) is guideline-concordant.
Infection risk and HBV reactivation prevention remain appropriately addressed - Secondary G-CSF prophylaxis started 2025-09-15; inflammatory markers low (CRP 0.33 mg/dL, 2025-09-08). - Anti-HBc positive on anti-CD20 therapy; Vemlidy (tenofovir alafenamide) continuation is appropriate through and beyond therapy.
[Plan / Recommendation]
Neuropathy-focused actions before cycle 5 (anticipated ~2025-09-29) - Grade neuropathy at next clinic using CTCAE v5.0 sensory and motor criteria - If grade 2 (interferes with function but not ADLs): hold Oncovin (vincristine) until recovery to ≤ grade 1, then resume at reduced dose per protocol. - If grade ≥3 or progressive despite dose reduction: omit Oncovin (vincristine) and proceed with R-miniCHOP minus V as clinically appropriate. - Initiate Cymbalta (duloxetine) if symptoms are painful or functionally impactful - Start 30 mg QD for 7 days, then increase to 60 mg QD if tolerated. - Monitor BP, Na, LFTs at baseline and within 2–4 weeks; counsel on nausea, somnolence, dry mouth. - Reassess effect by 2–4 weeks; deprescribe if no benefit. - Non-pharmacologic adjuncts - Encourage daily foot/hand protection, balance precautions, gentle aerobic activity and home PT exercises; consider referral to oncology rehabilitation. - Consider topical options (e.g., menthol) for focal dysesthesias; avoid OTC supplements with bleeding or neuroactive risks without review.
Antiemetic optimization to mitigate vincristine neurotoxicity risk - Discuss with oncology whether to trial a NK1-sparing regimen on upcoming cycles if emesis risk permits - Option: Aloxi (palonosetron) + dexamethasone ± Zyprexa (olanzapine) 5–10 mg at night for 2–3 days. - If NK1 is required, continue Akynzeo but intensify neuropathy monitoring and be prepared for vincristine dose adjustment.
Constipation care (maintain improvements and prevent ileus) - Continue Through (sennoside) HS and Mosapin (mosapride) TID; add polyethylene glycol 17 g QD and titrate to 1–2 soft BMs/day. - Hydration target ≥1.5–2.0 L/day if not contraindicated; encourage fiber and mobility. - Red flags (urgent evaluation): abdominal distension, vomiting, inability to pass gas, severe cramping.
HBV prophylaxis and monitoring during rituximab therapy - Continue Vemlidy (tenofovir alafenamide) through at least 12 months after final Rituxan (rituximab) dose. - Check HBV DNA and LFTs every 1–3 months during therapy and for at least 12 months post-rituximab.
Safety and monitoring labs - Pre-cycle labs within 48–72 hours before next chemotherapy: CBC with diff, CMP (including Na, K, BUN, Creatinine, AST/ALT, bilirubin), LDH; consider magnesium level. - If starting duloxetine: add BP and Na check at 2–4 weeks; reassess sedation given concurrent Eurodin (estazolam). - Continue G-CSF secondary prophylaxis days +2 to +5 post-chemotherapy as ordered; reinforce fever precautions (≥38.0°C).
Education and documentation - Provide the patient a simple daily neuropathy and bowel log (0–10 intensity scale, distribution, interference with activities, BM frequency/consistency). - Instruct to bring the log to the next visit to facilitate accurate grading and treatment decisions. - Communicate the above recommendations to the oncology team and flag the potential NK1–vincristine neurotoxicity interaction for shared decision-making.
Follow-up - Pharmacist phone check in ~7–10 days after potential duloxetine initiation to assess tolerability and symptom change. - Reassess neuropathy grade prior to cycle 5; adjust regimen accordingly.
20250917 followup 門診化療後的狀況, 致電病人由其子接聽, 其子表示目前便祕的現象已有好轉, 但 neuropathy 仍維持沒有消退, 我告知其子轉告病人, 下次回診時要把 neuropathy 的變化描述給醫師知道, 與醫師討論看是否要調整化療組套的用藥 (vincristine) 或者是加上治療藥如 duloxetine 等
Key Insights / Summary
Problem 1. DLBCL, stage IV, high-risk, interim response to therapy
Problem 2. Chemotherapy-related cytopenias and anemia
Problem 3. Vincristine-related peripheral and autonomic neuropathy with constipation
Problem 4. Hepatobiliary/pancreatic involvement and hepatitis B risk under anti-CD20 therapy
Problem 5. Renal function and electrolytes
Problem 6. Cardiovascular risk under anthracycline exposure and preexisting diastolic dysfunction
Problem 7. Infection risk and prior UTI
Problem 8. Gastrointestinal mucosal disease and dyspepsia
Problem 9. Musculoskeletal/bony lesion and right distal fibula lucency
Problem 10. Symptom control, sleep, and quality of life
Problem 11. Medication reconciliation and interactions
Plan Summary (next steps)
[Vincristine-induced neuropathy (VIPN)]
Vincristine-induced neuropathy (VIPN) remains a common and challenging side effect of vincristine chemotherapy, with limited evidence-based treatments proven to reverse or prevent neuropathic symptoms. Current evidence supports symptom-focused management, dose modifications, and some investigational agents, but there is no universally accepted curative intervention.1
Guideline-Endorsed Strategies
Symptomatic Pharmacologic Management
Investigational and Experimental Treatments
Several agents have been evaluated in preclinical or early-phase clinical studies for VIPN:
Other Approaches
Summary Table
| Strategy Type | Agent/Action | Evidence |
|---|---|---|
| Dose modification | Dose reduction/capping | Strong (guideline supported) 3 |
| Symptom treatment | Duloxetine, Gabapentin, TCAs | Moderate/low (mainly extrapolated) 1 |
| Experimental | Glutamine, Curcumin, Liraglutide, Others | Early/Preclinical 52 |
| Physical therapy | PT/OT, pain clinic referral | Supportive, widely used 3 |
Clinical Pearls
Further research is ongoing to identify and validate effective neuroprotective and disease-modifying therapies specific for vincristine-induced neuropathy.6
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
[netupitant can increase vincristine exposure]
The primary mechanism is the inhibition of the cytochrome P450 3A4 (CYP3A4) enzyme by netupitant. Vincristine is extensively metabolized by CYP3A4; when netupitant is co-administered, it reduces vincristine metabolism and clearance, resulting in higher systemic concentrations of vincristine. This pharmacokinetic interaction raises the risk for vincristine-related toxicity, including neuropathy and other adverse effects.28
Mechanism Details
This interaction is clinically significant, especially when other CYP3A4 inhibitors (like certain azoles or macrolides) are present or in pediatric/neurotoxic risk populations.3
Key Insights / Summary
Problem 1. Diffuse large B-cell lymphoma (DLBCL), stage IV, high-risk IPI
Problem 2. Anemia
Problem 3. Hepatobiliary and pancreatic involvement
Problem 4. Cardiovascular status (not posted)
Problem 5. Renal function (not posted)
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
Key insights / Summary
Problem 1. Sepsis due to catheter-associated complicated UTI with gram-negative bacteremia
Problem 2. Metastatic HER2-positive breast cancer with leptomeningeal carcinomatosis; on Enhertu (trastuzumab deruxtecan)
Problem 3. Drug-related liver injury vs HBV-related flare; improving hepatic profile on Vemlidy (tenofovir alafenamide)
Problem 4. Hemodynamics: hypotension episodes with hypoalbuminemia and poor oral/NG intake
Problem 5. Malnutrition and sarcopenia with functional decline
Problem 6. Anemia and thrombocytopenia
Problem 7. Electrolyte and metabolic issues
Problem 8. Pain, constipation, and sedation balance
Problem 9. Mental health: depression with suicidality; safety planning
Problem 10. Indwelling devices (Foley, NG, Port-A) and infection risk
Problem 11. Pulmonary lesion vs infection vs drug toxicity
Problem 12. Goals of care and disposition
Medications referenced (current/prn as recorded 2025-09-16 to 2025-09-17): Enhertu (trastuzumab deruxtecan), Merrem (meropenem), Plasbumin-20 (human albumin), Akynzeo (netupitant/palonosetron), Decadron (dexamethasone), Benadryl (diphenhydramine), Ativan (lorazepam; brand per local formulary Anxiedin), Trintellix/Brintellix (vortioxetine), Eurodin (estazolam), Nexium (esomeprazole), LACTUL (lactulose), Senokot (sennosides; Through), Durogesic (fentanyl patch), Painkyl (fentanyl buccal film), MSIR (morphine immediate-release), Bao-Gan (silymarin), Vemlidy (tenofovir alafenamide).
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
Key insight / summary
Problem 1. Relapsed/refractory DLBCL now on tafasitamab + lenalidomide
Problem 2. Recurrent right chylothorax / malignant pleural effusion
note for problem 2 (not for post): Rationale for Sandostatin (octreotide) in chylothorax management
Problem 3. Hematologic status and therapy-related cytopenia risk
Problem 4. Venous/arterial thrombosis prophylaxis on Revlimid (lenalidomide) ± megestrol
Problem 5. Renal function and electrolytes (CKD 3a, recent hyponatremia)
Problem 6. Cardiac rhythm/QTc and drug interactions
Problem 7. Infection risk and prophylaxis while on anti-CD19 + IMiD
Problem 8. Hepatitis B core antibody positive on antiviral prophylaxis
Problem 9. COPD with recurrent atelectasis from effusion
Problem 10. Type 2 diabetes, currently well controlled
Problem 11. Nutrition, sarcopenia, and weight trajectory
Problem 12. Peripheral neuropathy and fall risk
Problem 13. BPH with nocturia/overactive bladder
Medication housekeeping relevant today
Follow-up checkpoints
The 92-year-old male patient has diffuse large B-cell lymphoma (DLBCL, Stage IV, IPI:3) with bilateral pleural effusion, chronic kidney disease (CKD) stage 3a, type 2 diabetes mellitus, and hypertensive heart disease. He is undergoing R-COP chemotherapy (rituximab, cyclophosphamide, vincristine, prednisolone) every three weeks, with C4 administered on 2025-02-11. Recent findings include:
Problem #1: Diffuse Large B-cell Lymphoma (DLBCL, Stage IV, IPI:3)
Problem #2: Bilateral Pleural Effusion and Suspected Pneumonia
Problem #3: Chronic Kidney Disease (CKD) Stage 3a
Problem #4: Hypokalemia
Problem #5: Herpes Simplex (Resolved)
Suggested Plan
Primary Diagnosis: Diffuse Large B-cell Lymphoma (DLBCL)
Bilateral Pleural Effusion
Chronic Kidney Disease (CKD) Stage 3
Type 2 Diabetes Mellitus (T2DM)
Hypokalemia
Chronic Obstructive Pulmonary Disease (COPD)
Herpes Simplex Infection
Cardiac Considerations
Nutritional Deficiency
This is a 91-year-old male with diffuse large B-cell lymphoma (DLBCL) undergoing his second cycle of R-mini COP chemotherapy. His clinical course is complicated by chronic kidney disease (stage 3a), type 2 diabetes mellitus, atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD) with acute exacerbation, electrolyte imbalance, and bilateral pleural effusions requiring recurrent interventions. He presents for chemotherapy with additional findings of dyspnea, hypocalcemia, hypoalbuminemia, and signs of malnutrition.
[exam finding]
[MedRec]
[surgical operation]
[consultation]
[chemotherapy]
Key insights / summary
Problem 1. Esophageal squamous cell carcinoma, cT3N1M0, on definitive concurrent chemoradiation
Problem 2. Cisplatin nephrotoxicity/ototoxicity risk and supportive care during CCRT
Problem 3. Myelosuppression with marked lymphopenia
Problem 4. Cisplatin-related electrolyte disturbances (hypomagnesemia ± potassium shifts)
Problem 5. Treatment-related nausea and hiccup
Problem 6. Nutrition and dysphagia risk during RT
Problem 7. Cardiovascular status and blood pressure control
Problem 8. Indeterminate skeletal uptake on bone scan; degenerative disease favored
Problem 9. Port-A care
Problem 10. Comorbidities: hyperlipidemia; renal stones; viral hepatitis screen
Medication reconciliation today (selected, using Brand Name [generic name])
Follow-up checkpoints
[exam finding]
[MedRec]
[immunochemotherapy]
….-..-.. -
2024-07-16 - nivolumab 3mg/kg 200mg NS 100mL 1hr + ramucirumab 8mg/kg 500mg NS 250mL 1.5hr + liposome doxorubicin 20mg/m2 40mg D5W 500mL 1.5hr
[lab data]
2025-02-17 FLT3-D835 (BM) Undetectable
2025-02-17 NPM1 mutation (qual) (BM) Presence of mutation
2025-02-10 FLT3/ITD mutation (BM) Undetectable
2025-02-10 JAK2 mutation (quan) 0.00 %
2024-12-27 HLA B-high 58:01
2024-12-27 HLA C-high 01:02
2024-12-27 HLA C-high 03:02
2024-12-27 HLA DQ-high 02:01
2024-12-27 HLA DQ-high 04:01
2024-12-27 HLA DR-high 03:01
2024-12-27 HLA DR-high 04:05
2024-11-20 HLA A-high 24:02
2024-11-20 HLA A-high 26:01
2024-11-20 HLA B-high 54:01
2024-11-20 HLA B-high 58:01
2024-11-20 HLA C-high 01:02
2024-11-20 HLA C-high 03:02
2024-11-20 HLA DQ-high 02:01
2024-11-20 HLA DQ-high 04:01
2024-11-20 HLA DR-high 03:01
2024-11-20 HLA DR-high 04:05
2024-11-07 FLT3-D835 (BM) Undetectable
2024-11-05 FLT3/ITD (BM) Undetectable
2024-11-05 NPM1 (qual)(BM) Presence of mutation
2024-11-05 JAK2 (quan) 0.00 %
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2025-09-03 - methotrexate 15mg/m2 26mg NS 250mL 0.5hr
2025-08-27 - fludarabine 30mg/m2 50mg NS 250mL 1hr + melphalan 70mg/m2 122mg NS 500mL 1hr (FluMel140-ATG)
2025-07-31 - azacitidine 75mg/m2 130mg 2min SC QD D1-7
2025-07-02 - azacitidine 75mg/m2 130mg 2min SC QD D1-7
2025-05-21 - azacitidine 75mg/m2 130mg 2min SC QD D1-7
2025-04-21 - azacitidine 75mg/m2 130mg 2min SC QD D1-7
2025-03-19 - azacitidine 75mg/m2 137mg 2min SC QD D1-7
2025-02-11 - azacitidine 75mg/m2 140mg 2min SC QD D1-7
Key insights / summary
Problem 1. Post-allo-PBSCT day +15 with severe neutropenia and early neutrophil recovery
Problem 2. GVHD prophylaxis/status post-transplant
Problem 3. Cytopenias: anemia and thrombocytopenia post-conditioning
Problem 4. Electrolyte abnormalities related to therapy (CsA-associated Mg wasting; prior K issues)
Problem 5. Infection prophylaxis/antimicrobial stewardship
Problem 6. Metabolic / glycemic status and nutrition
Problem 7. Cardiovascular/renal/hepatic function under calcineurin inhibitor
Problem 8. Central venous access (Hickman) care
Overall plan (today 2025-09-18)
Key insight / summary
Problem 1. Post-allo PBSCT (D+10) with profound neutropenia and infection risk
Problem 2. GVHD prophylaxis with Sandimmun (cyclosporine) and Methotrexate (methotrexate)
Problem 3. Post-conditioning cytopenias (anemia and thrombocytopenia)
Problem 4. Electrolyte issues (hypomagnesemia, prior hypokalemia)
Problem 5. Gastrointestinal/mucositis and nausea; nutrition risk
Problem 6. Type 2 diabetes / steroid-related dysglycemia
Problem 7. Cardiovascular status and blood pressure on Cartil (diltiazem) with Sandimmun (cyclosporine)
Problem 8. Central venous access device (Hickman) care
Overall plan checkpoints for the next 72 hours
Key insight / summary
Problem 1. Early post-allo PBSCT state with severe neutropenia and infection risk
Problem 2. GVHD prophylaxis and calcineurin inhibitor management
Problem 3. Electrolyte disturbances (hypokalemia, hypomagnesemia) and cardiac safety
Problem 4. Hemodynamics and prior ATG-related reaction vs occult infection
Problem 5. Metabolic and endocrine: type 2 diabetes in neutropenic phase
Problem 6. Cardiovascular and blood pressure management during transplant
Problem 7. Nutrition, weight trend, and GI tolerance
Problem 8. Line care and thrombosis/infection prevention
Overall disposition - Continue current inpatient neutropenia pathway on day +7 with daily CBC/CMP/Mg, CsA trough monitoring, culture-based stewardship, transfusion support, and aggressive infection surveillance. Anticipate engraftment within the next 1–2 weeks barring complications; prepare discharge education on GVHD warning signs and infection precautions once counts recover.
Key insight / summary (2025-08-29 to 2025-09-05)
Problem 1. Day +3 status post allo-PBSCT for MDS-EB-2 (Fludarabine/Melphalan/ATG)
Problem 2. Possible sepsis vs ATG infusion reaction with high PCT/CRP
Problem 3. GVHD prophylaxis and calcineurin-inhibitor therapeutic drug monitoring
Problem 4. Severe neutropenia with evolving cytopenias
Problem 5. Electrolyte repletion during conditioning/immunosuppression
Problem 6. Glucose control in type 2 diabetes during peri-transplant steroids
Problem 7. Nausea/vomiting and constipation under chemotherapy
Problem 8. Central venous catheter (Hickman) care
Problem 9. Viral risk management (CMV/HSV/VZV)
Problem 10. Nutrition and functional status
Planned near-term actions today (2025-09-05)
Key Insight/Summary
Problem 1. Peri-transplant status after allo-PBSCT (Day +1)
Problem 2. Possible early sepsis vs ATG infusion reaction (hypotension, inflammatory markers)
Problem 3. Cytopenia risk and transfusion thresholds (not posted)
Problem 4. GVHD prophylaxis, drug interactions, and therapeutic drug monitoring (not posted)
Problem 5. Central line (Hickman) care and catheter-related infection risk (not posted)
Problem 6. Infection prophylaxis and viral serostatus (not posted)
Problem 7. Type 2 diabetes and peri-transplant glucose control (not posted)
Problem 8. Gastrointestinal symptoms and constipation (not posted)
Problem 9. Cardiovascular/antihypertensive management around hypotension (not posted)
Problem 10. Electrolyte stewardship and renal/hepatic function protection (not posted)
Current Medication Highlights (selected, by brand name) (not posted)
Disposition/Monitoring Checklist (next 24–48 h) (not posted)
The patient is a 43-year-old woman with refractory anemia with excess blasts-2 (RAEB-II, MDS-IB2 with NPM1 mutation), now admitted for conditioning chemotherapy before planned allogeneic HSCT on 2025-09-02. She has received prior cycles of azacitidine plus Venetoclax, with therapy discontinued on 2025-08-11 in preparation for transplant. Current conditioning regimen includes fludarabine and melphalan, with ATG and GVHD prophylaxis (cyclosporine, methotrexate) scheduled. She is clinically stable with ECOG PS 2, Hickman catheter in place, stable vital signs, no fever, and preserved renal/hepatic function (Cr 0.33mg/dL, eGFR 230.1, AST 13U/L, ALT 18U/L on 2025-08-24). Hematologically, she is in remission-like status with normalized counts (Hb 13.8g/dL, PLT 330k/uL, WBC 2.3k/uL on 2025-08-24). Infectious screening is negative (HBV, HCV, HIV, HTLV all non-reactive; CMV IgG positive, CMV IgM negative on 2025-08-26). She has comorbidities of type 2 diabetes, hypertension, hyperlipidemia, and joint contractures. Key issues include transplant readiness, infection prophylaxis, glycemic control, constipation, and supportive management during conditioning.
Problem 1. Transition to Hematopoietic Stem Cell Transplantation (HSCT)
Problem 2. Hematological Status
Problem 3. Infection Prophylaxis
Problem 4. Gastrointestinal Symptoms / Constipation
Problem 5. Type 2 Diabetes Mellitus
Problem 6. Cardiovascular Function
Problem 7. Neuropathy and Joint Contractures
Problem 8. Renal and Hepatic Function
This is a 43-year-old female diagnosed with myelodysplastic syndrome with excess blasts-2 (RAEB-II) since 2024-10-29, with bone marrow blast percentages consistently around 15% (bone marrow 2025-06-23). She carries an NPM1 mutation and normal karyotype (46,XX20) and has been undergoing active treatment with Vidaza (azacitidine) and self-paid Venetoclax with intermittent use of Posaconazole for antifungal prophylaxis. Her clinical course is complicated by repeated pancytopenia, persistent deconditioning with joint contractures, neuropathic symptoms, episodes of hyperuricemia, and recent pulmonary findings of mild hypoinflation without functional impairment (PFT 2025-08-19). She remains transfusion-dependent at times but shows partial hematologic stabilization. No progression to overt AML has been confirmed so far.
Problem 1. Myelodysplastic Syndrome with Excess Blasts-2 (MDS-EB2), NPM1-mutant, planned for HSCT
Problem 2. Hematologic toxicity and anemia
Problem 3. Hyperuricemia (not posted)
Problem 4. Neuropathy and musculoskeletal pain (not posted)
Problem 5. Pulmonary findings and respiratory function (not posted)
Problem 6. Electrolyte and renal function trends (not posted)
Problem 7. Deconditioning and functional decline (not posted)
Problem 8. Transition planning toward Hematopoietic Stem Cell Transplantation (HSCT) (posted, 2025-08-25 version)
Problem 8. Transition planning toward Hematopoietic Stem Cell Transplantation (HSCT) (not posted, 2025-08-21 version)
[Bedside visit after family meeting]
Following the family meeting convened by the attending physician (Dr. Gao) from 10:30 to 11:30 in the 11A ward conference room, I visited the patient and family at bedside for a follow-up discussion.
Family Meeting Summary:
Pharmacist Interventions and Education:
Neuropathy Clarification:
Supportive Counseling:
[use of erythropoiesis-stimulating agents (ESAs)] (not posted)
According to a document from 2025-07-17, the NCCN Guidelines for Myelodysplastic Syndromes (MDS) provide the following evidence-based recommendations regarding the use of erythropoiesis-stimulating agents (ESAs):
The rationale is that higher blast counts (>10%) are associated with lower ESA responsiveness and increased risk of disease progression. Therefore, NCCN suggests evaluating both serum erythropoietin levels and marrow blast percentage before initiating ESAs.
Hence, my earlier recommendation—“Consider EPO-stimulating agents cautiously if erythropoietin level available and blasts remain <5–10%”—is supported by NCCN 2025 criteria.
This 43-year-old woman with myelodysplastic syndrome (MDS), subtype RAEB-II and confirmed NPM1 mutation (bone marrow 2025-02-17), is demonstrating evolving features consistent with acute myeloid leukemia (AML) transformation based on sustained peripheral blood blasts >20% (peaking at 50.0% on 2025-04-22) and markedly elevated WBC (up to 91.47 ×10^3/uL on 2025-05-15). Her clinical course includes recurrent anemia, persistent thrombocytopenia, episodic neutrophilia, systemic inflammation (CRP up to 20.3 mg/dL), and initiation of Vidaza plus Venetoclax from 2025-05-21. Neurological complications include arthropathy and possible sensory neuropathy. Hemodynamically stable as of 2025-05-22 but functionally impaired (ECOG PS 3).
Problem 1. AML transformation from MDS-RAEB-II
Problem 2. Inflammatory and infectious status
Problem 3. Anemia and thrombocytopenia
Problem 4. Arthropathy and neuropathic pain (not posted)
Problem 5. Peripheral neuropathy and neuromusculoskeletal pain
Problem 5. Peripheral neuropathy (old one, not posted)
[immunochemotherapy]
[exam finding]
[MedRec]
2025-09-08 SOAP Colorectal Surgery Lv ZongRu
2025-07-20 ~ 2025-08-27 POMR General and Gastroenterological Surgery Chen YuTien
2025-07-04, 2025-06-13, 2025-05-23, 2025-05-02 SOAP Hemato-Oncology Yang MuJun
2025-05-07 SOAP Neurology Liu XiuXun
2025-05-05 SOAP Cardiology Lin ShuangJin
2023-11-13 ~ 2023-11-27 POMR Colorectal Surgery Lv ZongRu
2023-09-25 ~ 2023-09-28 POMR Gastroenterology Xiao ZongXian
[surgical operation]
[chemotherapy]
[Duodart tube-feeding]
Available related drugs include:
Dutasteride capsules must not be crushed or opened for tube feeding because the contents are chemically irritant and can be absorbed through the skin, posing risks such as mucosal irritation and potential teratogenicity, especially in women of childbearing age.
The recommended dutasteride alternative in patients requiring tube feeding is to change therapy to finasteride, which can be safely dispersed in water and given via an enteral tube.
| ATC code | Name | DDD | U | Adm.R |
|---|---|---|---|---|
| G04CB01 | finasteride | 5 | mg | O |
| G04CB02 | dutasteride | 0.5 | mg | O |
Finasteride and dutasteride are both 5-alpha reductase inhibitors, but they differ in enzyme selectivity and clinical potency.5
Comparative Efficacy
| Medication | Standard Dose | DHT Suppression | Prostate Volume Reduction | Symptom Relief/BPH |
|---|---|---|---|---|
| Finasteride | 5 mg daily | ~70% 5 | 18% 7 | Effective 4 |
| Dutasteride | 0.5 mg daily | ~94–98% 5 | 25% 7 | Effective 4 |
Ref:
Problem 1. Acute gastrointestinal bleeding with symptomatic anemia and thrombocytopenia
Problem 2. Metastatic colorectal cancer (liver and probable lung), KRAS G12V, sequential multi-line therapy with current treatment limitation
Problem 3. Cholestatic jaundice and hepatic dysfunction, likely intrahepatic from metastases (below not posted)
Problem 4. Postoperative adhesive small-bowel obstruction/ileus risk
Problem 5. Tracheostomy-dependent airway with bilateral lung opacities; infection surveillance
Problem 6. Protein-calorie malnutrition; on parenteral nutrition
Problem 7. Renal dysfunction with metabolic acidosis; electrolyte disorders
Problem 8. Complicated urinary tract infection with candiduria; BPH
Problem 9. Hematologic cytopenias (thrombocytopenia, macrocytic anemia, neutrophil-predominant leukocytosis)
Problem 10. Cardiovascular disease with RBBB, possible ischemia, and aortic arch aneurysm
Problem 11. COPD with recent respiratory failure; currently stable oxygenation
Problem 12. Stress/TPN-related hyperglycemia without known diabetes
Cross-cutting recommendations
[exam finding]
[MedRec]
[Subjective]
Medication beliefs/adherence - He reports not taking Arcoxia (etoricoxib 60mg) 1# QD prescribed by Orthopedics due to fear of bleeding when combined with Bokey (aspirin 100mg) 1# QD and Brilinta (ticagrelor 90mg) 1# BID. - He understands after counseling that no “avoid combination” alert exists in our interaction checker but remains concerned about bleeding risk on dual antiplatelet therapy. - He acknowledges advice to maintain adequate daily hydration while on Xigduo XR (dapagliflozin 10mg, metformin 1000mg) 1# QDCC to aid glycosuria and mitigate potential NSAID-related renal adverse effects.
Lifestyle/monitoring - Smoking: continues ~1 pack/day; expresses willingness to reduce gradually per week but has not set a quit date. - Blood pressure: home systolic readings typically 140–150 mmHg. - He verbalizes understanding that incomplete adherence (e.g., not telling Orthopedics he discontinued Arcoxia) may mislead clinical decisions.
[Objective]
Key cardiac history and procedures - NSTEMI → PCI with bare-metal stent to RCA proximal–mid segment; final TIMI-3 flow (Cardiac cath 2025-08-20). - ECG evolved from ST-T abnormalities (ECG 2025-08-20) to sinus bradycardia with lateral T-wave abnormalities (ECG 2025-08-21). - Echo: preserved LV systolic function, M-mode EF 77.5%, concentric LVH, trivial MR/TR (Echo 2025-08-20).
Current medication list - Antiplatelet: Bokey (aspirin 100mg) 1# QD; Brilinta (ticagrelor 90mg) 1# BID. - Lipid: Atotin (atorvastatin 20mg) 1# QD. - GI protection: Nexium (esomeprazole 40mg) 1# QDAC. - Antihypertensives: Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# BID; Zanidip (lercanidipine 10mg) 1# QD; Concor (bisoprolol 1.25mg) 1# QD. - Diabetes: Xigduo XR (dapagliflozin 10mg, metformin 1000mg) 1# QDCC. - Others: Rivotril (clonazepam 0.5mg) 1# HS. - Orthopedics analgesic: Arcoxia (etoricoxib 60mg) 1# QD – not taking currently.
Recent pertinent data (2025-08-20) - Renal function: creatinine 0.94–1.07 mg/dL, eGFR 86.43 mL/min/1.73m². - Electrolytes: K 3.5–3.7 mmol/L, Na 142 mmol/L. - Glycemia: HbA1c 6.1%. - Lipids: triglyceride 290 mg/dL, LDL-C 119 mg/dL.
[Assessment]
Medication safety/interaction considerations - DAPT-associated bleeding risk: Adding any systemic NSAID, including a COX-2 selective agent (etoricoxib), increases GI/overall bleeding risk; PPI co-therapy (Nexium) lowers upper GI risk but does not abolish it (DAPT ongoing since 2025-08-20). - Post-MI CV risk: Systemic NSAIDs, particularly COX-2 inhibitors, carry thrombotic/CV risk; best avoided or minimized post-ACS unless benefits clearly outweigh risks; if needed, use the lowest effective dose for the shortest duration with cardiology awareness (Cath 2025-08-20; ACS status). - Renal risk (“triple whammy” potential): ARB/diuretic (Hyzaar) + NSAID (etoricoxib) + SGLT2 inhibitor (Xigduo XR) with suboptimal BP and possible volume depletion elevates AKI risk despite currently normal eGFR (labs 2025-08-20).
Therapeutic control/risk factors - Blood pressure above guideline target: Home SBP 140–150 mmHg vs goal <130/80 mmHg in CAD/T2DM if tolerated; NSAIDs may blunt antihypertensive effect and raise BP (home logs 2025-09-10). - Smoking: Ongoing daily use post-MI markedly increases reinfarction and mortality risk; cessation support is urgent. - Pain control gap: Elbow pain required Orthopedics Rx (2025-08-06) but patient is non-adherent due to safety concerns; needs safer, multimodal pain plan.
Adherence/education - Partial nonadherence (self-discontinued Arcoxia) and persistent concerns about drug interactions; requires shared plan across Cardiology/Orthopedics and explicit communication at next visits to avoid decision errors.
[Plan / Recommendation]
Analgesia strategy (stepwise, cardiac- and kidney-conscious) - First-line (preferred): - Acetaminophen (generic) 500–650 mg Q6–8H PRN; max 3,000 mg/day if no liver concerns. - Topical NSAID: diclofenac 1% gel to affected elbows QID as directed; monitor skin tolerance. - Non-pharmacologic: ice/heat as tolerated, elbow-focused physiotherapy and strengthening. - If pain persists after 5–7 days of above and function is limited: - Discuss with Orthopedics/Cardiology: - Short course of Arcoxia (etoricoxib) 60mg QD for ≤5 days at the lowest effective dose, only with: - Strict hydration (aim usual 2.0–2.5 L/day unless restricted), daily weight and BP checks. - Continue Nexium (esomeprazole) 40mg daily. - Avoid any additional OTC NSAIDs or antiplatelets. - Stop and seek care if melena, hematemesis, hematuria, unexplained bruising, edema, or reduced urine output. - Consider non-NSAID rescue options if needed (e.g., short course of tramadol with fall/sedation counseling) only after prescriber review.
Renal/BP monitoring around any systemic NSAID use - Labs: order BMP (SCr/eGFR, K, Na) 3–7 days after starting systemic NSAID and again at 10–14 days if continued (target draw 2025-09-17 ±2 days). - BP: home BP twice daily for 1–2 weeks; bring log to Cardiology; hold systemic NSAID if SBP rises >150 consistently or edema occurs. - Sick-day rule: if dehydrated (vomiting, poor intake, febrile illness), hold Xigduo XR temporarily and avoid NSAIDs; resume when euvolemic and eating/drinking normally.
Cardiovascular secondary prevention reinforcement - Continue DAPT: Bokey (aspirin) + Brilinta (ticagrelor) exactly as prescribed; do not add OTC NSAIDs or herbal products that increase bleeding (ongoing since 2025-08-20). - Lipids: verify LDL-C after statin titration window; coordinate with Cardiology for up-titration of Atotin (atorvastatin) toward high-intensity and add-on therapy if needed (recheck by 2025-09-24). - BP optimization: share home BP log; discuss titrating Zanidip (lercanidipine) and/or diuretic strategy with Cardiology to reach <130/80 mmHg if tolerated (visit goal: within 2–4 weeks).
Smoking cessation (high priority) - Set a concrete quit plan: - Option A: Varenicline (varenicline) standard start pack; set quit date within 1–2 weeks, continue for 12 weeks with counseling. - Option B: Nicotine patch + short-acting NRT (gum/lozenge) combination. - Provide referral to hospital cessation program and arrange follow-up call in 1 week to troubleshoot triggers and adherence.
Education and coordination - Reassure that the EHR interaction checker flags clinically significant issues; emphasize that absence of an “avoid” flag does not equal zero risk on DAPT—hence the stepwise pain plan and monitoring. - Instruct to inform Orthopedics and Cardiology about actual intake/non-intake of Arcoxia at next visits to avoid misinformed decisions. - Red flags to report immediately: black/tarry stools, coffee-ground emesis, hematuria, gum bleeding, easy bruising, sudden dyspnea/chest pain, ankle swelling, or drop in urine.
Follow-up and tasks - Phone follow-up in 3–5 days after initiating acetaminophen/topical NSAID (target 2025-09-13–2025-09-15) to assess pain control and adverse effects. - BMP around 2025-09-17 if any systemic NSAID was started. - Bring BP/smoking reduction log and medication list to next Cardiology OPD; reinforce adherence to DAPT and statin.
Areas for improvement (team and patient) - Align Orthopedics–Cardiology plan for musculoskeletal pain in post-ACS patients to minimize systemic NSAID exposure. - Establish a written, patient-friendly ‘pain ladder’ and ‘sick-day’ checklist. - Intensify smoking cessation support (pharmacotherapy + counseling) and BP management to guideline targets.
Here are the most relevant, up-to-date clinical guideline sources to use for this patient (NSTEMI, PCI with a bare-metal stent to proximal–mid RCA, triple-vessel CAD, HTN, T2DM, hypertriglyceridemia, active smoker). I’m listing each topic with the key guideline(s) to consult and the main takeaways you’ll likely apply.
Patient-specific step-by-step plan (based on 2025 ACC/AHA ACS, 2023 ESC ACS, 2021 ACC/AHA/SCAI Revascularization, 2025 ADA Standards, 2025 ESC/EAS Dyslipidaemia, ACC Hypertriglyceridemia consensus)
Key insights / summary
Problem 1. Acute NSTEMI with multivessel CAD, s/p PCI to RCA (BMS)
Problem 2. Hypertension with concentric LVH and diastolic dysfunction risk
Problem 3. Atherogenic dyslipidemia (LDL-C 119 mg/dL, TG 290 mg/dL at index event)
Problem 4. Type 2 diabetes with early diabetic kidney disease (microalbuminuria)
Problem 5. Tobacco use disorder with likely secondary polycythemia
Problem 6. Bradycardia and conduction abnormalities on beta-blocker
Problem 7. Electrolyte optimization for post-MI arrhythmia prevention
Problem 8. Gastroprotection while on DAPT; NSAID risk
Problem 9. Thyroid function borderline abnormal
Problem 10. Insomnia and sedative use post-MI
Planned monitoring and follow-up timeline
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Key insight / summary
Problem 1. Endometrial adenocarcinoma, FIGO 2023 IIIC1ii, high-grade endometrioid, status post surgery + CCRT + adjuvant chemotherapy
Problem 2. Progressive chronic kidney disease, likely cisplatin nephrotoxicity
Problem 3. Chemotherapy-induced peripheral neuropathy (CIPN), sensory predominant
note for problem 3 (not for post) - Let me explain why I said “as systemic therapy has completed” and what the guidelines actually say.
Problem 4. Anemia, normocytic, multifactorial (myelosuppression/inflammation; CKD contribution)
Problem 5. Prior neutropenia/thrombocytopenia, now recovered
Problem 6. Electrolyte balance with marginal magnesium and potassium
Problem 7. Exertional dyspnea
Problem 8. Insomnia and chronic benzodiazepine use
Problem 9. Constipation prevention under antiemetics and opioids/NSAIDs
Problem 10. Vascular access (Port-A)
Closing notes
The patient is a 63-year-old woman with FIGO stage IIIC1ii endometrial adenocarcinoma (grade 3, pT2N1aM0) status post staging surgery on 2025-02-24, receiving concurrent chemoradiotherapy with paclitaxel plus cisplatin. She completed 4 cycles of chemotherapy uneventfully (C1 on 2025-03-25, C2 on 2025-04-29, C3 on 2025-05-20, and C4 on 2025-06-17). Radiation (external beam and vaginal cuff brachytherapy) began on 2025-04-01. The clinical course remains stable with no acute toxicity, preserved ECOG PS 1, no signs of infection or tumor progression, and resolving CA-125 from 44.6 (2025-02-15) to 5.510 U/mL (2025-06-09). Labs show anemia (Hb 9.9 g/dL on 2025-06-16), marginal renal function (eGFR 49.17), and resolved neutropenia. Overall, she is tolerating therapy with supportive care, including magnesium and antiemetics.
Problem 1. Endometrial adenocarcinoma (FIGO IIIC1ii, pT2N1aM0, grade 3)
Problem 2. Anemia
Problem 3. Renal function (cisplatin nephrotoxicity risk)
Problem 4. Sleep disturbance and prior benzodiazepine use (not posted)
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[Subjective]
2025-09-10 phone follow-up with patient (osteoporosis/bone health while on AI) - Patient-reported BMD recheck - She underwent a community bone density test after the hospital DXA; result reportedly T-score -2.9 (date/location unknown; reported 2025-09-10). - She understands that T-score ≤ -2.5 indicates osteoporosis and higher fracture risk. - Calcium supplementation adherence/acceptability - She did not take the hospital-issued calcium due to large tablet size and has been self-purchasing smaller OTC calcium tablets. - She is willing to bring the outside BMD report next visit and discuss medication options with the surgeon (General & GI Surgery clinic, Dr. Zhang YaoRen).
[Objective]
Prior documented data - Cancer therapy - Femara (letrozole 2.5 mg) 1# QD, ongoing since 2023-04 (multiple renewals, e.g., 2025-09-03). - Adjuvant RT completed 2023-06-02 (40 Gy/16 fx + 10 Gy/4 fx boost). - Baseline bone status - DXA L1–4 BMD 0.855 g/cm², approx. T-score -1.5 (osteopenia) (2023-09-11). - Renal stone history - Left renal stone decreased from 0.54 cm (2025-06-02) to 0.42 cm (2025-08-25) on ultrasound. - Recent labs relevant to bone therapy safety - Ca 2.60 mmol/L (2023-04-06); creatinine 0.94 mg/dL, eGFR 63.7 mL/min/1.73m² (2025-06-02).
[Assessment]
AI-associated bone loss; probable progression from osteopenia to osteoporosis - Letrozole-associated accelerated bone loss places her at elevated fracture risk; patient-reported outside T-score -2.9 (2025-09-10) suggests osteoporosis requiring pharmacologic therapy. - Need to verify outside BMD (site, T-score by region, machine, date) and capture vertebral fracture assessment (VFA) status. - Therapeutic options discussed with patient for next clinic decision - Antiresorptives - Prolia (denosumab): q6-month SC; effective in AI-associated bone loss; requires adequate Ca/Vit D and dental clearance; rebound vertebral fracture risk on discontinuation without exit bisphosphonate. - Xgeva (denosumab): oncology dosing for SRE prevention; not indicated for primary osteoporosis; avoid confusion with Prolia regimen. - Annual IV zoledronic acid may be an alternative if adherence is a concern (not yet discussed with patient today). - Anabolics - Forteo (teriparatide): daily SC; limited to cumulative 24 months lifetime; useful in very low BMD or multiple fractures; requires subsequent antiresorptive to maintain gains. - Evenity (romosozumab): monthly for 12 months; carries CV caution; follow with antiresorptive. - Safety/individual factors - Renal function adequate for denosumab and zoledronic acid considerations (eGFR 63.7 mL/min/1.73m² on 2025-06-02). - History of left renal stone argues for careful calcium dosing and timing with meals; emphasize fluids and sodium moderation. - No recent serum Ca, 25(OH)D, or P levels available close to 2025-09-10; must check prior to antiresorptive initiation. - Adherence/acceptability opportunities - Pill size was a barrier; chewable or small-tablet calcium and liquid formulations may improve adherence.
[Plan / Recommendation]
Bone health management (to coordinate with surgeon/oncology at next visit) - Verify and document osteoporosis - Obtain and scan the outside BMD report (patient to bring at next visit); if unavailable, repeat DXA with VFA as feasible to establish baseline (hip + spine; consider forearm if degenerative changes). - Laboratory safety workup prior to therapy selection - Order: serum calcium, phosphorus, 25(OH)D, creatinine/eGFR (baseline and to correct deficiencies before therapy). - Consider baseline bone turnover marker (e.g., P1NP or CTX) for future response monitoring. - Pharmacotherapy options to present (final choice per prescriber after shared decision-making) - Option 1 (preferred antiresorptive): Prolia (denosumab) 60 mg SC q6 months - Pre-steps: dental evaluation to mitigate ONJ risk; correct vitamin D deficiency; ensure daily calcium intake 1000–1200 mg and vitamin D 800–1000 IU. - Monitoring: check calcium, phosphorus, and symptoms of hypocalcemia post-injection; plan an oral or IV bisphosphonate as an exit strategy if/when Prolia is stopped to prevent rebound vertebral fractures. - Option 2 (anabolic-first for very low BMD or high fracture risk): Evenity (romosozumab) monthly for 12 months or Forteo (teriparatide) daily up to 24 months - Follow with an antiresorptive (e.g., alendronate weekly or zoledronic acid yearly) to consolidate gains. - Screen CV risk if considering romosozumab; review cost/coverage. - Clarify that Xgeva (denosumab) is oncology dosing and not used for primary osteoporosis; avoid substitution errors. - Calcium/vitamin D and lifestyle optimization - Formulation: switch to chewable calcium carbonate or smaller calcium citrate tablets; split doses with meals to enhance absorption and reduce stone risk. - Targets: calcium 1000–1200 mg/day total from diet + supplements; vitamin D 800–1000 IU/day (adjust to 25(OH)D 30–50 ng/mL). - Hydration ≥ 2–2.5 L/day, sodium moderation, and routine weight-bearing + resistance exercise; fall-prevention strategies at home. - Renal stone precautions - Take calcium with meals; avoid excessive supplemental calcium beyond targets; consider 24-hour urine metabolic evaluation if stones recur or enlarge. - Follow-up and documentation - Education provided today regarding osteoporosis definition, fracture risk, and medication classes, including pros/cons. - Patient agrees to bring BMD report next surgical clinic visit and discuss options with Dr. Zhang YaoRen. - Pharmacy to re-evaluate adherence and tolerance to calcium/vitamin D formulations in 2–4 weeks; coordinate lab review and therapy initiation plan once prescriber orders are in place.
[Appropriateness Assessment of Breast Cancer Treatment (per NCCN v4.2025 - 20250417)]
Patient Profile
Assessment by Treatment Domain
Summary
Overall Conclusion
A. Key Insights/Summary
B. Problem-Oriented Deliberation
Problem 1. Early-stage HR+/HER2- breast cancer: disease control and surveillance
Problem 2. Aromatase inhibitor-associated bone loss with baseline osteopenia
Problem 3. Hypertension with recent low BP, LV hypertrophy and grade 1 diastolic dysfunction
Problem 4. Hyperlipidemia and atherosclerotic risk
Problem 5. Right breast benign lesion (probable fibroadenoma), BI-RADS 2
Problem 6. Nephrolithiasis, left kidney, decreasing size
Problem 7. Possible goiter with euthyroid labs
Problem 8. Elevated D-dimer without thrombotic symptoms (historical)
Problem 9. General laboratory status (hematology, electrolytes, glycemia, liver/renal)
Guideline anchors referenced above:
Adjuvant endocrine therapy duration in HR+/HER2– early breast cancer (per NCCN v4.2025):
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
2025-09-10 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-09-03 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-07-02 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-06-25 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-06-11 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-06-04 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-05-21 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-05-14 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-04-30 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-04-23 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-03-26 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-03-19 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-03-05 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-02-26 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-02-12 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-02-05 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-01-22 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-01-15 - sacituzumab govitecan 10mg/kg 710mg NS 250mL 1.5hr (Trodelvy)
2025-01-08 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-12-25 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-12-18 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-11-27 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-11-13 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-11-06 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-10-23 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2024-10-16 - eribulin mesylate 1.4mg/m2 2.4mg NS 50mL 10min (Halaven)
2022-07-27 - docetaxel 75mg/m2 135mg NS 250mL 1hr (Nolbaxol)
2022-06-28 - docetaxel 75mg/m2 135mg NS 250mL 1hr (Nolbaxol)
2022-06-01 - docetaxel 75mg/m2 134mg NS 250mL 1hr (Nolbaxol)
2022-05-11 - docetaxel 75mg/m2 135mg NS 250mL 1hr (Nolbaxol)
2022-04-20 - epirubicin 90mg/m2 163mg NS 100mL 30min + cyclophosphamide 600mg/m2 1084mg NS 500mL 1hr
2022-03-30 - epirubicin 90mg/m2 162mg NS 100mL 30min + cyclophosphamide 600mg/m2 1078mg NS 500mL 1hr
2022-03-09 - epirubicin 90mg/m2 163mg NS 100mL 30min + cyclophosphamide 600mg/m2 1082mg NS 500mL 1hr
2022-02-16 - epirubicin 90mg/m2 163mg NS 100mL 30min + cyclophosphamide 600mg/m2 1084mg NS 500mL 1hr
[Subjective]
Telephone follow-up on 2025-09-10 - Unable to reach the patient; the patient’s daughter answered the call. - Requested her to remind the patient to discuss increasing calcium and vitamin D supplementation at the next General Surgery visit, in light of ongoing Xgeva (denosumab) therapy and bone metastases risk. - No direct symptom report available today due to inability to contact the patient.
[Objective]
Tumor marker trajectory (CA15-3) - Rising over time with fluctuations - 2022-10-07: 59.188 U/mL (nuclear medicine) - 2022-12-14: 46.8 U/mL - 2023-03-07: 37.7 U/mL - 2023-03-15: 62.88 U/mL (nuclear medicine) - 2023-06-05: 51.7 U/mL - 2023-09-05: 54.8 U/mL - 2023-12-07: 52.2 U/mL - 2024-03-01: 40.7 U/mL - 2024-09-06: 43.8 U/mL - 2025-01-02: 62.5 U/mL - 2025-04-09: 74.7 U/mL - 2025-07-02: 71.4 U/mL - CEA 4.49 ng/mL (2025-07-02)
Recent labs and organ function (for treatment safety) - CBC/CMP within treatment parameters - WBC 4.71 x10^3/µL, neutrophils 49.0% (ANC ≈ 2.3), Hgb 11.4 g/dL, Plt 294 x10^3/µL (2025-09-10) - Cr 0.68 mg/dL, eGFR 92.88 mL/min/1.73m^2, AST/ALT 16/15 U/L, Na 137 mmol/L, K 3.9 mmol/L (2025-09-10)
Oncologic imaging and pathology context - Pathology conversion to ER-/PR-/HER2 1+ with extranodal extension on right axillary node excision (2024-10-04) - Metabolic and skeletal partial response on therapy - PET partial metabolic response (2025-04-09) - Bone scan shows less-evident lesions vs prior; no new lesions (2025-07-08) - CT chest shows no pulmonary metastasis and Port-A tip in SVC (2025-07-25)
Current anticancer and supportive therapies - Trodelvy (sacituzumab govitecan) ongoing day 1/8 q21d; most recent doses 2025-09-03 and 2025-09-10 with standard premedications (betamethasone, diphenhydramine, Akynzeo [netupitant/palonosetron]) - Xgeva (denosumab) 120 mg Q4W initiated 2025-09-03 - Fulphila (pegfilgrastim) support used per-cycle as needed (e.g., 2025-09-10) - Port-A in place; heparin lock flush per orders
[Assessment]
CA15-3 trend interpretation in context of imaging - While CA15-3 has risen compared with some earlier lows, the trajectory from 2025-01-02 (62.5 U/mL) to 2025-07-02 (71.4 U/mL) is modest and imaging demonstrates partial response without new lesions (PET 2025-04-09; bone scan 2025-07-08; CT 2025-07-25). - CA15-3 is useful for trend-following but cannot independently define progression; clinical and imaging correlation is required.
Treatment tolerability and safety - Counts and chemistries on 2025-09-10 support continued Trodelvy without dose delay; mild normocytic anemia (Hgb 11.4 g/dL) is expected. - Ongoing risk for neutropenia, diarrhea, and mucositis with Trodelvy warrants anticipatory guidance and rapid-response plan.
Bone health under denosumab - Xgeva reduces skeletal-related events but requires adequate calcium and vitamin D to mitigate hypocalcemia; dental/jaw precautions are needed due to ONJ risk. - Maxilla/mandible uptake on multiple bone scans historically suggests dental issues may coexist, increasing ONJ risk if invasive dental work occurs.
Communication and adherence - The patient was not directly reached on 2025-09-10; message relayed via daughter regarding supplementation discussion. - Ensuring reliable communication channels is important for timely toxicity reporting and adherence.
[Plan / Recommendation]
Marker and disease monitoring - Continue CA15-3 and CEA every 1–2 cycles, always interpreting alongside symptoms and imaging. - Recommend next restaging around 2025-10 to 2025-11 unless symptoms evolve sooner, using PET/CT or bone scan aligned with prior modalities for comparability.
Trodelvy (sacituzumab govitecan) safety bundle - Pre-dose checks each day 1 and day 8: CBC with differential, vitals, symptom/toxicity review. - Hold/modify per label thresholds (e.g., day 1 ANC < 1.5 x10^3/µL; day 8 ANC < 1.0 x10^3/µL; grade ≥3 diarrhea). - Early antidiarrheal plan: loperamide at first loose stool; maintain hydration; check electrolytes if ≥ grade 2 diarrhea. - Oral care: soft toothbrush, bland rinses; report ulcers early. Consider prophylactic topical agents if prior mucositis develops. - Reinforce fever action plan: temperature ≥ 38.0°C warrants same-day evaluation for possible neutropenic fever.
Denosumab-associated supplementation and labs - Suggest calcium and vitamin D supplementation to discuss and implement with the doctor: - Calcium (elemental) 1,000–1,200 mg/day in divided doses; consider calcium citrate or chewable formulations if large tablets are difficult to swallow. - Vitamin D3 800–1,000 IU/day; check 25-OH vitamin D and replete if < 30 ng/mL. - Laboratory surveillance every 8–12 weeks while on Xgeva: - Corrected calcium, phosphate, magnesium, and 25-OH vitamin D; more frequent checks if diarrhea, poor intake, or symptoms (paresthesia, muscle cramps) occur. - Dental precautions: - Schedule dental evaluation; optimize oral hygiene; avoid elective extractions during therapy when possible; promptly report jaw pain, swelling, or loosening teeth.
Supportive and general measures - Nutrition: monitor weight and albumin; involve dietitian if intake declines or weight loss is noted. - Port-A care: continue heparin lock per protocol; educate on signs of line infection or thrombosis. - Symptom education: RUQ pain, jaundice, or fever may indicate gallstone complications; prompt reporting advised given known cholelithiasis.
Communication improvements - Confirm preferred contact numbers and times; consider adding an alternate contact method (e.g., messaging portal) to reduce missed communications. - Provide printed/translated treatment calendar and toxicity hotline information at next clinic visit.
Follow-up actions - At next General Surgery/Oncology visit: finalize calcium/vitamin D regimen; order baseline calcium/phosphate/magnesium and 25-OH vitamin D if not already obtained; review CA15-3 trend with imaging plan. - Pharmacist to re-attempt direct patient contact within 3–5 days to reinforce education on Trodelvy toxicities and supplementation adherence, and to assess for any interim symptoms.
Key insights / summary
Problem 1. Metastatic triple-negative breast cancer on Trodelvy
Problem 2. Skeletal metastases and bone health on Xgeva
Problem 3. Myelosuppression risk and infection prevention on Trodelvy
Problem 4. Gallbladder stones (asymptomatic cholelithiasis)
Problem 5. Organ function surveillance (renal, hepatic, electrolytes, nutrition)
Problem 6. Cardiovascular surveillance post-anthracycline exposure
Problem 7. Central venous access (Port-A) care
Problem 8. Historical receptor conversion and biomarker strategy
Follow-up and monitoring plan (practical)
Reminders and rationales for the patient
Appropriateness review of the patient’s management (2020-2025), aligned to NCCN Breast Cancer Guidelines Version 4.2025 with rationale and timestamped evidence.
Overall conclusion
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Key insight / summary
Problem 1. High-risk endometrioid carcinoma of the uterus, adjuvant therapy ongoing
Problem 2. Chemotherapy tolerance and hematologic toxicity (recovered)
Problem 3. Intercurrent gastrointestinal issues: adhesive small-bowel obstruction; rectosigmoid wall thickening likely post-radiation
Problem 4. Indeterminate lesions on prior oncologic imaging (left iliac bone; breast)
Problem 5. Hepatitis B exposure with prophylaxis during cytotoxic therapy
Problem 6. Electrolyte balance and renal/hepatic function (adequate for C3)
Problem 7. Ototoxicity and neurotoxicity risk
Problem 8. Constipation and dyspepsia around chemotherapy
Problem 9. Cardiovascular screening signal on historical ECG
Closing note
Key Insight / Summary
Problem 1. Uterine endometrioid carcinoma (stage IIC, post CCRT, on adjuvant chemotherapy)
Problem 2. Anemia (likely chemotherapy-related)
Problem 3. Leukopenia (chemotherapy-induced)
Problem 4. Electrolyte imbalance: Borderline hypokalemia and low-normal magnesium
Problem 5. HBV carrier status under antiviral therapy
[exam finding]
[MedRec]
[consultation]
[is the diagnosis Gorham–Stout disease correct?]
The available records clearly and consistently document the diagnosis as Gorham–Stout disease (Gorham’s disease) with bilateral chylothorax, progressive osteolysis, spinal cord compression, and pleural complications.
Taken together, the diagnosis of Gorham–Stout disease is correct and well supported:
Differential diagnoses such as metastatic cancer, lymphoma, osteomyelitis, or Langerhans cell histiocytosis are unlikely, since pathology excluded malignancy/infection and the pattern is diffuse osteolysis with lymphatic leakage.
So yes — the diagnosis of Gorham–Stout disease is correct based on histopathology, imaging, and clinical evolution.
For an academic case report manuscript, the highlights or “selling points” of this patient are strong because of the combination of rarity, severity, and multidisciplinary complexity:
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
Key insights/summary
He is a 37-year-old man with esophagogastric junction adenocarcinoma, pT1bN1 (stage IIB) after R0 3D VATS esophagectomy with gastric tube reconstruction (2025-07-07), with negative margins and 1/38 nodes positive, LVI present, PNI absent (Pathology 2025-07-08). Staging showed no distant disease (CT 2025-06-13; PET 2025-07-01; bone scan 2025-07-02; brain MRI 2025-06-30).
He is admitted for adjuvant therapy: Imfinzi (durvalumab) plus FLOT every 2 weeks (oxaliplatin, leucovorin, 5-FU, Taxotere [docetaxel]) beginning 2025-09-08, with standard premedication/antiemetics (dexamethasone, diphenhydramine, famotidine, palonosetron, aprepitant) and hydration (MAR 2025-09-08).
Baseline organ functions are adequate for cytotoxic therapy: WBC 8.26 x10^3/uL, Hgb 12.8 g/dL, Plt 298 x10^3/uL (2025-09-07); ALT 29 U/L, AST 15 U/L, Tbili 0.89 mg/dL, creatinine 0.79 mg/dL, eGFR 117 mL/min/1.73m^2, K 3.7 mmol/L, Mg 2.1 mg/dL (2025-09-07). Vitals are stable (2025-09-08 08:15 and 13:31).
He has mild eosinophilia (7.4%) likely atopy/asthma related (CBC diff 2025-09-07) and hyperuricemia (uric acid 8.8 mg/dL, 2025-09-07). HBV and HCV screens are nonreactive with protective anti-HBs 29.68 mIU/mL (2025-08-08).
Post-op UGI series suggested anastomotic narrowing with contrast retention (UGI 2025-07-29); he reports intermittent vomiting (ROS 2025-09-07). Port-A site has mild oozing but no infection (PE 2025-09-08).
The uploaded NCCN Head & Neck v5.2025 (2025-08-12) adds an option for neoadjuvant Keytruda (pembrolizumab) in resectable stage III–IVa non-nasopharyngeal disease with PD-L1 CPS≥1, with linked adjuvant pathways, and clarifies workup (including mandatory p16 for oropharynx and PD-L1 testing), postoperative RT timing (≤6 weeks), and standard RT doses. (this item not posted)
Problem 1. Head & neck cancer management plan — amended per NCCN v5.2025 (2025-08-12) (not posted)
Problem 1. pT1bN1 esophagogastric junction adenocarcinoma, post-esophagectomy, adjuvant therapy selection and execution (old version, not posted)
Problem 2. Postoperative gastric tube–small bowel anastomotic narrowing with emesis risk
Problem 3. Respiratory comorbidity and infection risk (asthma history, prior pneumonias), cough management
Problem 4. Anticipated toxicities and supportive care for FLOT ± Imfinzi (posted)
Problem 5. Hyperuricemia with history of gout, currently starting xanthine oxidase inhibitor
Problem 6. Cardiovascular comorbidity (hypertension, tachycardia at times) during chemotherapy
Problem 7. Port-A site oozing
Problem 8. Gastroesophageal reflux disease/Barrett’s esophagus status post resection
Problem 9. Hematologic trends and prior postoperative reactive thrombocytosis
Problem 10. Medication reconciliation and optimization
Follow-up and monitoring plan - Labs each cycle: CBC with diff, CMP, magnesium; uric acid if adjusting ULT; thyroid panel for durvalumab. - Post-cycle toxicity check at day 7–10 (neutropenia nadir window) and day 14 prior to next FLOT. - Imaging re-staging after 3–4 cycles or earlier if symptoms.
[exam finding]
[MedRec]
2024-11-22 ~ 2024-11-25 POMR Hemato-Oncology Xia HeXiong
2024-10-28 ~ 2024-11-01 POMR Colorectal Surgery Xiao GuangHong
2024-10-15 ~ 2024-10-18 POMR Gastroenterology Wang JiaQi
[surgical operation]
[immunochemotherapy]
Key insight / summary
Problem 1. Possible infection under chemotherapy
Problem 2. Metastatic colon adenocarcinoma, RAS-mutated, pMMR/MSS, likely progression on FOLFOX+bevacizumab
Problem 3. Cancer-associated thrombosis: partial SMV thrombosis
Problem 4. Anemia (multifactorial: iron deficiency + anemia of chronic disease; acute drop)
Problem 5. Fluid, electrolytes, and renal/hepatic function
Problem 6. Blood pressure lability and antihypertensive management
Problem 7. HBV reactivation prophylaxis under chemotherapy
Problem 8. Pain, GI protection, and constipation
Notes on systemic therapy evidence for next line
[lab data]
2024-06-25 HBsAg Nonreactive
2024-06-25 HBsAg Value 0.60 S/CO
2024-06-25 Anti-HBs 32.01 mIU/mL
2024-06-25 Anti-HBc Nonreactive
2024-06-25 Anti-HBc Value 0.22 S/CO
2023-02-10 Anti-HBc Nonreactive
2023-02-10 Anti-HBc Value 0.60 S/CO
2023-02-10 Anti-HBs 32.66 mIU/mL
2023-02-10 Anti-HCV Nonreactive
2023-02-10 Anti-HCV Value 0.05 S/CO
2023-02-10 HBsAg Nonreactive
2023-02-10 HBsAg Value 0.40 S/CO
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Key insight / summary
Problem 1. Metastatic endometrioid adenocarcinoma (lung-only disease) on Lipodox/Cisplatin
Problem 2. Cisplatin-related renal function decline
Problem 3. Chemotherapy-related cytopenias: macrocytic anemia, leukopenia, thrombocytopenia
Problem 4. Right buttock furuncle during chemotherapy-induced immunosuppression
Problem 5. Cardiovascular status under anthracycline exposure; hypertension and hyperlipidemia
Problem 6. Gastrointestinal adverse effects and supportive care
Problem 7. Electrolyte/metabolic profile (including uric acid)
Problem 8. Central venous access (Port-A) and thrombosis/infection prevention
Additional general recommendations
This is a 68-year-old woman with stage IV high-grade endometrioid adenocarcinoma with lung metastases. She is undergoing palliative chemotherapy with liposomal doxorubicin and cisplatin (Q3W), now at Cycle 6 (2025-07-15). Disease is clinically stable with improved lung nodules after initial Taxol/Carboplatin and ongoing Lip-Dox/Cisplatin. Complications include grade II leukopenia, macrocytic anemia, and manageable chemotherapy-related nausea and constipation. Renal, hepatic, and electrolyte parameters remain stable. ECOG PS remains at 2, and vital signs are stable.
Problem 1. Metastatic endometrioid adenocarcinoma (stage IV)
Problem 2. Chemotherapy-induced leukopenia and anemia
Problem 3. Renal function under cisplatin therapy (not posted)
Problem 4. Gastrointestinal adverse effects (nausea, constipation) (not posted)
Problem 5. Comorbidities: hypertension, hyperlipidemia, insomnia
This 68-year-old woman with FIGO stage IV endometrioid adenocarcinoma (initially stage IB, now with confirmed lung metastasis) has undergone extensive treatment including staging surgery (2023-02-01), CCRT with cisplatin and radiotherapy (2023-03 to 2023-04), followed by paclitaxel/carboplatin chemotherapy (2024-06 to 2024-11), and currently receiving palliative liposomal doxorubicin plus cisplatin (C1: 2025-02-18 to C5: 2025-06-11). Lung metastases were confirmed on lung biopsy (2024-06-27) with PET/CT and chest CT progression noted by 2025-01-03. She has persistent normocytic macrocytic anemia, intermittent leukopenia, and stable renal and hepatic function. Her current ECOG status is 2, and she remains afebrile with stable vitals. The overall clinical course reflects a stable disease burden with chemotherapy-induced cytopenias as the major limiting factor.
Problem 1. Metastatic endometrial adenocarcinoma (lung metastasis, stage IV)
Problem 2. Chemotherapy-induced cytopenias (anemia and leukopenia)
Problem 3. Renal function monitoring (cisplatin use)
Problem 4. Cardiac function surveillance (not posted)
Problem 5. Chronic comorbidities (HTN, hyperlipidemia, insomnia)
[proactive neutropenia management in reduced-dose chemotherapy]
Currently, paclitaxel and carboplatin are being administered at 80% of the standard dose, but neutropenia is still present.
To mitigate this, administering G-CSF at the appropriate time during treatment may help manage the development of neutropenia and reduce its severity.
2024-10-08 WBC 2.38 x10^3/uL
2024-09-18 WBC 1.52 x10^3/uL
2024-09-08 WBC 2.33 x10^3/uL
2024-08-28 WBC 1.26 x10^3/uL
2024-08-18 WBC 2.39 x10^3/uL
2024-10-08 Neutrophil 63.0 %
2024-09-18 Neutrophil 52.3 %
2024-09-08 Neutrophil 63.9 %
2024-08-28 Neutrophil 42.8 %
2024-08-18 Neutrophil 69.1 %
[optional G-CSF prophylaxis after reduced paclitaxel and carboplatin dose]
Neutropenia was observed after the administration of paclitaxel and carboplatin. The session initiated on 2024-08-19 used 90% of the original dose. Prophylactic G-CSF might be also prepared in advance after the administration.
2024-08-18 WBC 2.39 x10^3/uL *
2024-07-22 WBC 4.25 x10^3/uL
2024-07-09 WBC 1.23 x10^3/uL
2024-06-26 WBC 3.54 x10^3/uL
2024-08-18 Neutrophil 69.1 %
2024-07-22 Neutrophil 67.3 %
2024-07-09 Neutrophil 9.6 %
2024-06-26 Neutrophil 72.9 %
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Ref]
Chemotherapeutic regimens used for the treatment of Hodgkin lymphoma - 2025-03-03 - https://www.uptodate.com/contents/image?imageKey=HEME%2F74186
Key insight / summary
Problem 1. Classical Hodgkin lymphoma, stage IV, on BV-AVD; interim PR, PET-avid ileocolic node (DS5) pending adjudication
Problem 2. Chemotherapy-related hematologic toxicity: cyclic neutropenia with post–G-CSF leukocytosis/left shift; anemia; intermittent thrombocytopenia (posted)
Problem 3. Anthracycline exposure with prior perioperative VT history; cardiac function preserved
Problem 4. Organ function and electrolytes: preserved renal/hepatic function; managed hypomagnesemia history
Problem 5. Supportive care toxicities: nausea, constipation, skin rash/pruritus; neuropathy surveillance
Problem 6. Co-morbid gynecologic condition: huge uterine myoma, stable during lymphoma therapy
Medications in use or recently used (selection relevant to above)
Answer to staging question
This 38-year-old woman has classical Hodgkin lymphoma, nodular sclerosis type, involving the pericardium (diagnosed 2025-01-24) and staged as Ann Arbor stage IV due to extranodal invasion. She has been receiving BV-AVD Q2W chemotherapy with acceptable tolerance, currently at Cycle 4 Day 15 (2025-06-25). Disease shows partial metabolic response on PET (2025-04-30), with new right subphrenic uptake suggestive of possible residual/recurrent disease. She remains clinically stable with G1 side effects only, including anemia (Hb 10.5 g/dL) and fatigue. No major organ dysfunction is detected.
Problem 1. Classical Hodgkin lymphoma, stage IV (invasion of pericardium)
Problem 2. Chemotherapy-induced anemia and thrombocytopenia
Problem 3. Leukocytosis post G-CSF (below not posted)
Problem 4. Constipation and appetite loss
Problem 5. Electrolyte and organ function monitoring
[S - Subjective]
The patient, a postpartum mother, confirmed she is not currently breastfeeding, eliminating concerns about medication safety for lactation.
The patient reported skin rash with itching over four limbs. Medications have already been prescribed to manage these symptoms.
[O - Objective]
Recent Chemotherapy (2025-03-03):
Cardiac Function:
Active Medication List:
[A - Assessment]
Hodgkin Lymphoma (Stage IIB) undergoing BD-AVD chemotherapy:
Skin Rash:
Electrolyte Monitoring:
Cardiac Considerations:
GI Protection:
[P - Plan & Recommendations]
Monitor for Chemotherapy-Related Toxicities:
Continue Current Medications:
Electrolyte Management:
Cardiac Follow-Up:
Patient Education:
Summary
Summary
This 38-year-old woman has been diagnosed with classical Hodgkin lymphoma (nodular sclerosis subtype) based on histopathology from mediastinal lymph node and thymus (2025-01-24). The disease was initially detected via CT chest (2025-01-13, 2025-01-15), which revealed a mediastinal mass with extensive lymphadenopathy.
The PET (2025-02-06) showed hypermetabolic activity in mediastinal, supraclavicular, pleural, and bone marrow regions (Deauville Score 2-3). However, bone marrow biopsy (2025-02-07) was negative for malignancy, no evidence of direct bone marrow involvement for now.
Based on nodal involvement limited to above the diaphragm (mediastinal, supraclavicular, pleural), and the presence of B symptoms (e.g., fever, weight loss, or night sweats, if present), her Hodgkin lymphoma should be Stage IIB under the Lugano classification.
Problem 1. Classical Hodgkin Lymphoma (Stage IIB)
Problem 2. Pulmonary Complications (Pleural Effusion, Pneumonia, Vocal Cord Paralysis) (below not posted)
Problem 3. Hematologic Complications (Anemia, Thrombocytosis, Leukocytosis)
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2025-09-02 - cytarabine 40mg/m2 60mg SC D1-7 (LDAC)
2025-07-25 - azacitidine 75mg/m2 113mg SC D1-7 (Vidaza)
2025-06-25 - azacitidine 75mg/m2 113mg SC D1-7 (Vidaza)
2025-04-24 - azacitidine 75mg/m2 113mg SC D1-7 (Vidaza)
2025-03-27 - azacitidine 75mg/m2 114mg SC D1-7 (Vidaza)
2025-03-04 - azacitidine 75mg/m2 113mg SC D1-7 (Vidaza)
2025-01-13 - azacitidine 75mg/m2 113mg SC D1-7 (Vidaza)
Key insight / summary
Problem 1. AML transformed from MDS with profound pancytopenia, on LDAC
Problem 2. Thrombocytopenia, severe and transfusion dependent
Problem 3. Transfusion-related iron overload, on Jadenu (deferasirox)
Problem 4. Neutropenia with recent sepsis workup and VRE faecium bacteriuria
Problem 5. Anemia, transfusion dependent
Problem 6. Electrolyte disturbances, hypokalemia now corrected; borderline magnesium
Problem 7. Hypertensive heart disease with cardiomegaly; BP control during chemotherapy
Problem 8. Bone health: osteopenia, chronic T12/L3 compression fractures with pain control needs
Problem 9. Peptic disease history and gastroprotection
Problem 10. Nutrition risk and hypoalbuminemia
Medication reconciliation notes (safety)
Follow-up checkpoints for the next 72 hours
This is a 71-year-old woman with myelodysplastic syndrome with increased blasts-1 (MDS-IB1), IPSS-R score 8.5 (very high risk), WPSS 5 (very high risk), diagnosed via bone marrow biopsy on 2024-12-17. She has undergone 5 prior cycles of Vidaza (azacitidine) and is now admitted for planned cycle 6 (C6D1 on 2025-07-25). While bone marrow blasts have declined from 5–10% to 1% (biopsy 2025-04-29), peripheral cytopenias persist, with transfusion dependence for both red cells and platelets. Notably, serum ferritin has risen from 1136.2 ng/mL (2024-12-13) to 2598.6 ng/mL (2025-06-23), consistent with transfusion-related iron overload. Jadenu (deferasirox) 720 mg/day was appropriately initiated. Renal and hepatic function remain within normal limits, allowing continuation of chelation and disease-directed therapy.
Problem 1. Pancytopenia with Blasts (MDS-IB1)
Problem 2. Severe Thrombocytopenia
Problem 3. Transfusion-Dependent Anemia with Iron Overload
20 transfusions
Problem 4. Hypertension
Problem 5. Dental and Musculoskeletal Symptoms (not posted)
The patient is a 70-year-old female with a history of myelodysplastic syndrome (MDS) with increased blasts and fibrosis, classified as very high risk (IPSS-R: 8.5, WPSS: 5). She is currently undergoing Cycle 2 of azacitidine (Vidaza) therapy (2025-03-04 to 2025-03-10). Persistent pancytopenia (severe anemia, leukopenia, thrombocytopenia) is noted, necessitating red blood cell transfusion (2025-03-04, 2 units LPRBC planned).
Other significant findings include:
The patient’s overall condition is stable (ECOG PS 1 on 2025-03-04), with good intake, absence of fever, and mild postural dizziness.
Problem 1. Myelodysplastic Syndrome (MDS) with Increased Blasts
Problem 2. Thrombocytopenia
Problem 3. Severe Anemia (Hgb 5.5 g/dL)
Problem 4. Polyneuropathy
Final Recommendations
[Jadenu (deferasirox) is recommended]
Based on the patient’s body weight of 55 kg and a calculated deferasirox dose of 14 mg/kg (770 mg total daily dose), treatment with Jadenu (deferasirox 360 mg/tab) 2 tablets QD is recommended.
Given the ferritin level of 1136.2 ng/mL (2024-12-13), which exceeds the 1000 ng/mL threshold for iron overload, iron chelation therapy should be initiated to prevent end-organ damage associated with chronic transfusions. Regular ferritin monitoring every 4-8 weeks is advised to assess treatment response and adjust the chelation regimen as needed.
[Is Azacitidine the Cause of Thrombocytopenia?]
Vidaza (azacitidine) can cause thrombocytopenia as a known adverse effect. However, in this patient’s case, the thrombocytopenia is likely multifactorial rather than solely drug-induced.
Conclusion:
[exam finding]
[MedRec]
[Subjective]
Medication understanding and use
Hepatitis B and imaging follow-up
Sleep and daytime function
[Objective]
Cardiovascular disease status and testing
Gastrointestinal risk
Renal, hematology, electrolytes (for medication safety)
Lipids and risk factors
Hepatobiliary imaging
Active medication list
[Assessment]
Chronic coronary syndrome on medical therapy; antiplatelet strategy with GI risk - Single antiplatelet therapy with Plavix (clopidogrel) is appropriate given no PCI and recent ulcer (CAG 2025-08-27; EGD 2025-07-29). PPI gastroprotection is indicated; pantoprazole preferred to avoid CYP2C19 interaction with clopidogrel. The patient understands bleeding precautions.
Beta-blocker titration and safety checks - Concor (bisoprolol) instruction per patient recall is 1.25 mg twice daily with hold parameters; prior documented regimen was 1.25 mg daily. Given normal renal function and low-normal K, beta-blocker titration is feasible; monitor for bradycardia, hypotension, and fatigue (labs 2025-08-26; CTA HR 62–65 bpm 2025-08-06).
Dyslipidemia: statin intensity below secondary prevention targets - LDL-C 94 mg/dL exceeds typical ASCVD targets (<55–70 mg/dL). Crestor (rosuvastatin) 10 mg every other day is subtherapeutic for secondary prevention; hepatic profile and HBV status allow escalation with monitoring (labs 2024-04-19; HBV carrier, US 2024-12-11).
Insomnia with early awakenings; chronic benzodiazepine exposure - Persistent maintenance insomnia (4-hour awakenings) diminishes daytime function. Current regimen includes Rivotril (clonazepam) nightly alongside Leeyo (escitalopram). - Considering Dayvigo (lemborexant) is reasonable for sleep maintenance, but should not be simply added to benzodiazepine without a taper plan due to additive CNS depression and fall risk. Lemborexant is CYP3A substrate; review for interacting drugs (none strong currently). Escitalopram adds minor bleeding risk with clopidogrel and may contribute to somnolence/QTc concerns; ECG and symptom monitoring are prudent.
HBV carrier follow-up and safety with cardiometabolic therapy - HBV carrier with normal recent imaging by report; ensure continued HCC surveillance and LFT monitoring during statin up-titration. No contraindication identified for statin intensification or PPI use (US 2024-12-11; patient report 2025-09-03).
Drug–drug/condition interactions and safety points - Clopidogrel + SSRI: modestly increased bleeding risk; reinforce GI protection and bleeding surveillance. - Bisoprolol + clonazepam: bradycardia, hypotension, sedation risk; caution if moving to BID dosing. - Potential PPI addition: favor Pantoloc (pantoprazole) to minimize clopidogrel interaction. - Lemborexant (if initiated) + clonazepam: additive sedation; plan substitution with taper rather than combination.
[Plan / Recommendation]
Antiplatelet and GI protection
Beta-blocker regimen reconciliation and counseling
Lipid management optimization
Insomnia management strategy
HBV and hepatology coordination
Laboratory/monitoring orders and timelines
Patient education and teach-back (reinforced today)
Follow-up and coordination
Key insights / summary
Problem 1. Chronic coronary syndrome with proximal stenosis (CTA LCX-ostium vs CAG ramus intermediate), managed medically
Problem 2. Antiplatelet strategy in the context of recent gastric ulcer
Problem 3. Suboptimal lipid management in established ASCVD
Problem 4. Blood pressure and cardiometabolic risk factor control
Problem 5. Symptomatic palpitations with low documented arrhythmia burden
Problem 6. Active peptic ulcer disease and GI protection while on cardioprotective therapy
Problem 7. Osteoporosis with T8 compression fracture on Prolia (denosumab)
Problem 8. Chronic hepatitis B carrier with benign liver cysts
Problem 9. Anxiety and nonorganic sleep disorder on paroxetine and benzodiazepines
Problem 10. Organ function, electrolytes, and hematology status
Problem 11. Data reconciliation and safety checklist
Medication optimization summary (actionable today, 2025-09-03)
Pharmacist follow-up priorities on 2025-09-03
Summary pharmacist action plan for 2025-09-03
Medication in use
Pharmacist follow-up checklist on 2025-09-03 (based on current active medications)
Summary pharmacist action plan for 2025-09-03
[exam finding]
[MedRec]
2025-01-15, 2024-10-23, 2024-07-31, 2024-05-08 SOAP Gastroenterology Gong ZiXiang - Prescription x3 - Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC - Acetal (acetaminophen 500mg) 1# PRNQID if pain
Key insights / summary
Problem 1. Sepsis from complicated urinary tract infection with left obstructive uropathy
Problem 2. Obstructive uropathy due to suspected urothelial carcinoma with metastases
Problem 3. Acute kidney injury on chronic kidney disease (below not posted)
Problem 4. Normocytic anemia in malignancy/CKD with recent hypovolemia
Problem 5. Hypoalbuminemia and nutrition/inflammation risk
Problem 6. Pericardial effusion with low-voltage ECG
Problem 7. Diabetes mellitus with recent hypoglycemia during poor intake
Problem 8. Electrolytes, minerals, and uric acid
Problem 9. Cardiovascular disease and dyslipidemia/atherosclerosis
Problem 10. Pain and supportive/palliative care needs
Problem 11. VTE prophylaxis and bleeding risk
Problem 12. Gallbladder stones with distention (incidental)
Disposition and next steps
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Subjective]
Pharmacist follow-up (respondent: wife and daughter)
[Objective]
Cancer, procedures, and staging
Renal/urinary stone workup and urinalysis
Recent vitals and labs
Active/pertinent medications (per records around 2025-08-26 to 2025-09-03)
[Assessment]
Adjuvant chemotherapy status and supportive care
Constipation, now improved
Alpha-1 blocker intolerance and LUTS management
Renal stones with hydronephrosis and rising creatinine
Calcium/vitamin D management post-thyroidectomy
HBV prophylaxis during chemotherapy
Anemia
[Plan / Recommendation]
Chemotherapy supportive care and education
Bowel regimen (prevention and rescue)
Alpha-1 blocker use and BP safety
Nephrolithiasis, hydronephrosis, and renal preservation
Calcium/calcitriol rationalization (post-thyroidectomy)
HBV prophylaxis
Anemia workup and management
Adherence and follow-up
The 63-year-old man has stage IIA (high-risk) adenocarcinoma of the descending-sigmoid colon, status post laparoscopic left hemicolectomy on 2025-06-03 (pathology: pT3N0M0, perineural invasion positive, 0/22 nodes). He was admitted on 2025-08-26 for C1D1 adjuvant chemotherapy with leucovorin/5-fluorouracil. He also has significant comorbidities: chronic obstructive pulmonary disease (with restrictive impairment and bronchiectasis), hypertensive heart disease, chronic viral hepatitis B under Vemlidy (tenofovir alafenamide) prophylaxis, history of old pulmonary tuberculosis, multiple renal stones with left hydronephrosis, and recent near-total thyroidectomy (2025-07-15) for nodular goiter complicated by transient hypocalcemia. His baseline labs on 2025-08-26 showed stable renal and hepatic function, Hb 10.0 g/dL (microcytic hypochromic anemia), platelets 286K, and electrolytes within normal limits. He remains ECOG 1, stable vital signs, and Port-A is functioning well.
Problem 1. Colon adenocarcinoma (pT3N0M0, stage IIA, high-risk)
Problem 2. Hematological problem – Anemia
Problem 3. Renal stone disease with left hydronephrosis
Problem 4. Chronic viral hepatitis B under antiviral prophylaxis
Problem 5. Pulmonary disease – COPD, bronchiectasis, prior TB
Problem 6. Post-thyroidectomy status with hypocalcemia history
Problem 7. Cardiovascular comorbidity – hypertensive heart disease, diastolic dysfunction
[Subjective]
Pharmacist follow-up
Caller: pharmacist contacted the patient’s family to follow up on post-discharge medication use.
Respondent: patient’s son.
Pharmacist counseling provided:
[Objective]
Clinical history and interventions
Current medications
[Assessment]
Medication adherence
Bruising
Secondary prevention and GDMT
Infection concern
[Plan / Recommendation]
Medication adherence and safety
HF and secondary prevention optimization
Electrolyte and monitoring
Infection reassessment
Sleep/anxiety management
Rehabilitation and lifestyle
Follow-up
Patient Review
Problem 1. STEMI (anterior wall, LAD-P 100% occlusion) s/p PCI with DES (2025-08-12)
Problem 2. LV dysfunction: HFmrEF (LVEF 48.8%) with LAD-territory hypokinesia, concentric LVH, grade 1 diastolic dysfunction
Problem 3. Hyperlipidemia with suboptimal LDL control (LDL-C 150 mg/dL)
Problem 4. Infection concern (high PCT and neutrophil-predominant WBC on 2025-08-13)
Problem 5. Hypertension and secondary prevention
Problem 6. Arrhythmia risk and electrolytes
Problem 7. Bleeding risk with DAPT
Problem 8. Early discharge against advice and cardiac rehab adherence
Problem 9. Anxiety/insomnia management
Problem 10. Organ function surveillance
Pharmacist follow-up priorities for 2025-09-03
[exam finding]
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
She is a 74-year-old woman with p16+ right tonsillar squamous cell carcinoma, staged cT1N1M0, treated with concurrent chemoradiotherapy (weekly cisplatin completed 2025-07-16; radiotherapy 33 fractions completed 2025-08-07) (MRI 2025-06-02; radiotherapy course 2025-06-17→2025-08-07). During 2025-07→08 she developed infectious complications including UTI (Escherichia coli) (urine culture 2025-07-21), Acinetobacter nosocomialis bacteremia (blood cultures 2025-08-07 and 2025-08-09), and clinical pneumonia with repeated CXRs showing increased lung markings and cardiomegaly (CXR 2025-08-07; CXR 2025-08-11; CXR 2025-08-23; CXR 2025-08-30). She was discharged 2025-08-30 and re-admitted the same day for fever; she is now afebrile and hemodynamically stable (vitals 2025-09-02 08:56). Inflammatory markers are modest but not normal (CRP 2.92 mg/dL, PCT 3.87 ng/mL) with improving WBC and platelets but persistent normocytic anemia (CBC 2025-09-01). UA on 2025-08-30 is negative for pyuria; urine culture on 2025-08-30 shows Enterococcus faecium 30,000 CFU/cc susceptible to vancomycin/teicoplanin (urine culture 2025-08-30). Renal function has recovered from earlier cisplatin-related decline (eGFR 57.61→96.41→89.90 mL/min/1.73m² from 2025-07-20→2025-08-30→2025-09-01). Ongoing dysphagia with NG since 2025-07-24 and hypoalbuminemia 2.9–3.3 g/dL in August (chemistry 2025-08-11; chemistry 2025-08-27). She currently receives Cinolone (ciprofloxacin) 250 mg PO BID AC, Takepron (lansoprazole) 30 mg PO QDAC, Norvasc (amlodipine) 5 mg PO QD, Eurodin (estazolam) 2 mg PO HS, Pilian (cyproheptadine) 4 mg PO TID, Xyzal F.C. (levocetirizine) 5 mg PO QD, Acetal (acetaminophen) 500 mg PO PRN Q6H, Actein Effervescent (acetylcysteine) 600 mg PO BID, Through (sennoside) 12 mg PO PRN HS, Vemlidy (tenofovir alafenamide) 25 mg PO QD, and 0.9% Saline IV (medication list 2025-09-01).
Problem 1. Fever with recent bacteremia/pneumonia, now clinically improving
Problem 2. Normocytic anemia, multifactorial (treatment-related, inflammation, malnutrition; possible occult GI blood loss) (not posted)
Problem 3. Enterococcal bacteriuria vs colonization after prior E. coli UTI (not posted)
Problem 4. Electrolyte abnormalities and QT risk during antimicrobial therapy; cisplatin-related renal Mg wasting history (not posted)
Problem 5. Nutrition compromise with dysphagia; NG in place since 2025-07-24; aspiration risk (not posted)
Problem 6. Right tonsillar squamous cell carcinoma, p16+, post-CCRT surveillance (not posted)
Problem 7. Renal function: recovered from cisplatin-related decline; continue monitoring (not posted)
Problem 8. Cardiopulmonary considerations: cardiomegaly on serial CXRs; NT-proBNP elevated once (not posted)
Problem 9. Thyroid function after neck irradiation: subclinical hypothyroidism
Problem 10. HBV exposure with prophylaxis; risk during cytotoxic therapy (not posted)
Problem 11. Sleep/pain management and fall risk (not posted)
Follow-up actions (near term) (not posted)
[Const-K tube feeding]
Const-K 750mg, the sole oral potassium supplement at this hospital, provides 10 mEq of potassium per extended-release tablet. If IV potassium isn’t preferred, these tablets can be finely crushed and mixed with water for easier intake.
This is a 74-year-old woman with right tonsillar squamous cell carcinoma, p16 positive (cT1N1M0, stage I), currently receiving concurrent chemoradiotherapy (CCRT) with cisplatin and radiotherapy. As of 2025-07-20, she presented to the emergency department with chills, low-grade fever, severe nausea/vomiting, and decreased oral intake. She was admitted due to suspected urinary tract infection (UTI) with leukopenia and thrombocytopenia under immunosuppressive stress from CCRT. Imaging shows no acute airway or pulmonary lesion. Her renal and hepatic functions remain relatively preserved, but ongoing mucositis and nutritional compromise may further threaten her recovery.
Problem 1. Suspected urinary tract infection under immunosuppression
Problem 2. Chemotherapy-induced myelosuppression
Problem 3. Radiation mucositis and esophagitis with poor oral intake
Problem 4. Renal function stability under nephrotoxic chemotherapy
Problem 5. Right tonsillar squamous cell carcinoma (p16+), under CCRT
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
2025-09-02 - paclitaxel 175mg/m2 NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Q3W)
2025-08-11 - paclitaxel 75mg/m2 107mg NS 250mL 2hr + carboplatin AUC 2 150mg NS 500mL 2hr (QW)
2025-08-04 - paclitaxel 75mg/m2 112mg NS 250mL 2hr + carboplatin AUC 2 150mg NS 500mL 2hr (QW)
2023-05-05 - docetaxel 75mg/m2 121mg NS 250mL 1hr
2023-04-14 - docetaxel 75mg/m2 118mg NS 250mL 1hr
2023-03-24 - docetaxel 75mg/m2 118mg NS 250mL 1hr
2023-03-03 - docetaxel 75mg/m2 115mg NS 250mL 1hr
2023-02-04 - liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 912mg NS 500mL 1hr
2022-12-19 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 856mg NS 500mL 1hr
2022-11-28 - liposome doxorubicin 35mg/m2 51mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 872mg NS 500mL 1hr (Endoxan prior to Lipo-Dox in prescription)
2022-10-31 - liposome doxorubicin 35mg/m2 49mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 848mg NS 500mL 1hr (Endoxan prior to Lipo-Dox in prescription)
[Note]
When doxorubicin and cyclophosphamide are given together (commonly as the AC regimen in breast cancer and other solid tumors), the usual sequence is: doxorubicin first, then cyclophosphamide. - 2025-09-02 - ChatGPT 5
Doxorubicin is typically administered before cyclophosphamide during chemotherapy regimens such as AC (doxorubicin + cyclophosphamide).13 - 2025-09-02 - Perplexity
Administration Sequence
Rationale for Sequencing
Administering doxorubicin first reduces the risk of tissue injury and follows established chemotherapy safety protocols.21
Ref:
Patient
Problem 1. Malignant small-bowel obstruction from recurrent ovarian carcinoma
Problem 2. Obstructive uropathy s/p right PCN with prior hydronephrosis
Problem 3. Systemic therapy strategy for recurrent endometrioid ovarian carcinoma
Problem 4. Volume status and electrolytes (dehydration, mild hyponatremia, calcium interpretation) (not posted)
Problem 5. Anemia, normocytic, multifactorial (cancer, prior chemo, inflammation) (not posted)
Problem 6. Infection risk and catheter care (port-A and PCN) (not posted)
Problem 7. HBV reactivation prevention during cytotoxic therapy (not posted)
Problem 8. Nutritional risk and weight loss with low albumin (not posted)
Problem 9. Antiemesis and symptom control (not posted)
Problem 10. VTE prophylaxis in hospitalized cancer patient (not posted)
Problem 11. Breast cancer history on endocrine therapy
Problem 12. Major depressive disorder and sedative burden (not posted)
Problem 13. Bowel regimen and pain (not posted)
Follow-up checkpoints over the next 48–72 hours (not posted)
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
Key insights / summary
Problem 1. Complicated urosepsis with bladder–uterine fistula and bilateral ureteral stents
Problem 2. Myelosuppression with febrile neutropenia risk
Problem 3. Severe anemia with ongoing risk of bleeding
Problem 4. Kidney injury on CKD with obstructive uropathy, metabolic acidosis, and hyponatremia (not posted)
Problem 5. Advanced endometrial carcinoma (T4N2M1, stage IVB) post RT with interval regression
Problem 6. Cardiometabolic monitoring and type-2 myocardial injury risk (not posted)
Problem 7. Nutrition, frailty, and symptom control (not posted)
Problem 8. Infection prevention and inpatient safety (not posted)
Active medications to continue/adjust during admission (as clinically appropriate) (not posted)
Follow-up checkpoints (next 24–48 h) (not posted)
[Findings and Recommendations]
Nausea and Vomiting Management
Pain Management Concerns
Tranexamic Acid Use for Bleeding Control
Anemia and Possible Iron Deficiency
Electrolyte and Renal Function Monitoring
[exam finding]
[MedRec]
[chemotherapy]
2025-08-26 - cytarabine 30mg/m2 45mg SC D1-7
2025-08-14 - cytarabine 30mg/m2 45mg SC D1-7
2025-07-14 - azacitidine 75mg/m2 120mg SC D1-7
2025-06-17 - azacitidine 75mg/m2 120mg SC D1-7
2025-05-12 - azacitidine 75mg/m2 123mg SC D1-7
[neutropenia]
Problem 1. Severe neutropenia in AML-transformed from MDS
The patient’s diagnosis has now clearly evolved from myelodysplastic syndrome with excess blasts-2 (MDS-EB2) to acute myeloid leukemia (AML), based on a combination of histopathological evidence and sustained blast elevation exceeding diagnostic thresholds. He has received multiple cycles of hypomethylating agents and currently is on Cytarabine plus Venetoclax-based regimens. However, the blast percentage continues to rise (peaking at 46.6% on 2025-08-27), signifying disease progression despite treatment. Given his age (74), comorbidities, and intermediate organ function, the treatment strategy needs to balance efficacy, tolerability, and eligibility for potential bridging to advanced options like HSCT.
Problem 1. AML transformation from MDS-EB2
Problem 2. Persistent pancytopenia with transfusion dependency
Problem 3. Risk of infection and neutropenic fever (not posted)
Problem 4. Nutritional risk and deconditioning
Problem 5. Electrolyte and renal profile monitoring (not posted)
[Deliberation on G-CSF Use for Neutropenia in This Patient] (not posted)
Summary of Patient’s Neutropenic Context
NCCN 2025 and Evidence-Based Deliberation
Final Assessment
Recommendations
References (?):
The 74-year-old male with a diagnosis of myelodysplastic syndrome with excess blasts-2 (MDS-EB2) since 2024-04 has now transformed into acute myeloid leukemia (AML), as evidenced by hypocellular marrow with 15–20% CD34+/CD117+ blasts (bone marrow 2025-08-12) and rising peripheral blasts (13.1% on 2025-08-15). He has received multiple cycles of azacitidine with suboptimal response, followed by the addition of Venetoclax with transient blast suppression. Despite persistent pancytopenia, transfusion dependence, and neutropenic episodes, his vital signs remain relatively stable. Chemotherapy with Cytarabine and Venetoclax has been resumed. The clinical focus is now on balancing cytoreduction, infection control, transfusion support, and symptom management.
Problem 1. AML transformation from MDS-EB2
Problem 2. Persistent pancytopenia with transfusion dependence
Problem 3. Neutropenia with history of sepsis
Problem 4. Weight loss and nutritional risk
Problem 5. Cardiopulmonary function and vital stability (not posted)
Problem 6. Iron overload from chronic transfusions
This 74-year-old man with myelodysplastic syndrome with excess blasts-2 (MDS-EB2), complex karyotype, and refractory pancytopenia is receiving azacitidine (Vidaza) chemotherapy. He is classified as very high-risk per IPSS-R. The clinical course shows persistent transfusion-dependent cytopenias, evolving neutropenia with relative lymphocytosis, critically low platelet counts (PLT <10k), and anemia (HGB <8.5 g/dL), despite multiple transfusions. Bone marrow biopsy on 2025-04-18 showed 24.3% blasts. Current vital signs remain stable with no fever or respiratory distress. Liver and kidney functions are preserved. Current azacitidine cycle started on 2025-06-17. Infection prophylaxis, transfusion support, and further blast monitoring remain critical.
Problem 1. Refractory Pancytopenia with Excess Blasts (MDS-EB2)
Problem 2. Severe Thrombocytopenia with Transfusion Dependence
Problem 3. Normocytic Anemia with Persistent Transfusion Requirement
Problem 4. Absolute Neutropenia with Lymphocyte Predominance
Problem 5. Hematologic Iron Overload Risk
[lab data]
2024-03-08 B2-Microglobulin (NM) 11.67 mg/L
2024-03-01 B2-Microglobulin 6642 ng/mL
2024-03-01 M-peak Positive
2024-02-17 M-peak Positive
[exam finding]
[MedRec]
[chemotherapy]
2025-06-27 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-06-20 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-06-13 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-06-06 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-05-30 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-05-23 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-05-16 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-05-09 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-05-02 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-04-25 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-04-18 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-04-11 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-03-28 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-03-21 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-03-14 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-03-07 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-02-21 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-01-17 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-01-10 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2025-01-03 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-12-27 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-12-20 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-12-13 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-12-06 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-11-29 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-11-22 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-11-15 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-11-01 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-10-25 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-10-18 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-10-11 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-10-04 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-09-27 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-09-06 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-08-30 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-08-23 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-08-16 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-08-09 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-08-02 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-07-26 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-07-19 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-07-12 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-05-03 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-04-26 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-04-19 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-04-12 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-03-29 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
2024-03-22 - Velcade (bortezomib) 1.3mg/m2 1.9mg SC 1min (VTD)
Key insights / summary
Problem 1. Rapidly progressive κ light chain multiple myeloma with end-organ damage (renal, bone, anemia, hypercalcemia)
Problem 2. Acute kidney injury on chronic kidney disease, likely myeloma cast nephropathy with contribution from hypercalcemia/dehydration
Problem 3. Hypercalcemia of malignancy, improving
Problem 4. Lower respiratory process: pneumonia vs cardiogenic congestion on background interstitial changes
Problem 5. Symptomatic anemia of chronic disease/marrow involvement
Problem 6. Persistent hypokalemia with mixed alkalosis pattern
Problem 7. Infection risk and inflammation in an immunocompromised host (not posted)
Problem 8. Skeletal disease, pain, fall risk, and osteoporosis (not posted)
Problem 9. Antiviral prophylaxis and drug safety with renal dysfunction (not posted)
Problem 10. Reported peripheral blasts on differential — rule out transient vs laboratory artifact (not posted)
Problem 11. Cardiovascular status and fluid–electrolyte stewardship (not posted)
Problem 12. Supportive care, VTE prophylaxis, and regimen-related risk (not posted)
Monitoring plan and next steps (immediate) (not posted)
Active medication notes (as of MAR in provided images) (not posted)
[exam finding]
[consultation]
[exam findings]
[MedRec]
2025-08-29 ~ 2025-08-31 POMR Colorectal Surgery Chen ZhuangWei
2025-08-25 SOAP Psychosomatic Medicine Lin JingEn
2025-08-22 SOAP Radiation Oncology Wang YuNong
2025-08-21 SOAP Gastroenterology Chen ZhiXiang
2025-08-15 ~ 2025-08-17 POMR Colorectal Surgery Chen ZhuangWei
2025-07-22 SOAP Neurology Xiao ZhenLun
2025-06-20 SOAP Cardiology Duan DeMin
[chemotherapy]
[lab data]
2025-02-20 HBsAg Nonreactive
2025-02-20 HBsAg Value 0.30 S/CO
2025-02-20 Anti-HCV Nonreactive
2025-02-20 Anti-HCV Value 0.25 S/CO
2025-02-20 Anti-HBc Nonreactive
2025-02-20 Anti-HBc Value 0.15 S/CO
2025-02-20 Anti-HBs 19.04 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[OxyContin controlled-release (oxycondone), UFT (tegafur 100mg, uracil 224mg) - tube feeding]
Opioid Formulation Adjustment
Clinical Recommendation: Hazardous Drug Handling (UFT)
Key insight / summary
Problem 1. Esophageal SCC, post-neoadjuvant CCRT and surgery, ypTisN0 (complete response)
Problem 2. Hypopharyngeal cancer/post-cricoid lesion status
Problem 3. Planned ‘scheduled chemotherapy’ today vs appropriateness after ypCR
Problem 4. Macrocytic anemia
Problem 5. Renal function and electrolyte safety after prior cisplatin
Problem 6. Nutrition after esophagectomy and risk of weight loss/dumping
Problem 7. Analgesia, cough, and hypnotic polypharmacy (sedation risk)
Problem 8. Type 2 diabetes mellitus
Problem 9. Dyslipidemia with low HDL (posted)
Problem 10. Infection/inflammation surveillance post-op
Problem 11. Cardiopulmonary baseline
Problem 12. Other oncologic/orthopedic considerations
Medication reconciliation highlights (selected)
Follow-up checkpoints and orders for today (2025-09-01)
Prioritized treatment suggestions as of 2025-09-01 (tailored to his current ypTisN0 status and recent data)
Summary message to team today
[OxyContin tube feeding]
Recommendation:
Rationale:
This is a 49-year-old male with dual malignancies: hypopharyngeal cancer (cT4aN0M0) and esophageal squamous cell carcinoma (cT3N2M0, stage IIIB). He completed definitive concurrent chemoradiotherapy (CCRT) with cisplatin, 5-fluorouracil, and self-paid Nivolumab on 2025-04-30. Post-treatment imaging (MRI 2025-05-15 and PET 2025-05-16) showed marked reduction of esophageal tumor burden and nodal uptake, but mildly increased FDG activity in the lower hypopharynx and inlet area with borderline neck LAPs. He was admitted on 2025-05-21 with fever, cough, and diarrhea, raising suspicion for post-CCRT infection. Soonmelt (amoxicillin/clavulanate) was started, and laparoscopic feeding jejunostomy was performed on 2025-05-26 due to progressive dysphagia and nutritional concerns. His nutrition shifted to pump feeding with gradual calorie escalation. Latest endoscopy (EGD 2025-05-29) noted partial regression of esophageal lesions, persistent inlet abnormality, and heterotopic gastric mucosa.
Problem 1. Esophageal squamous cell carcinoma, cT3N2M0, stage IIIB
Problem 2. Hypopharyngeal cancer, post-cricoid region, cT4aN0M0
Problem 3. Nutritional compromise and dysphagia
Problem 4. Infection (suspected bronchopneumonia and acute gastroenteritis)
Problem 5. Hematological suppression and anemia
[OxyContin tube feeding]
Recommendation:
Rationale:
Alternative:
Administration Instructions:
Summary
| Oxycodone Formulation | Tube Administration Allowed? | Notes |
|---|---|---|
| OxyContin (extended-release) | NO | Crushing/dissolving is unsafe. Do not use via tube |
| OxyNorm 5 mg (immediate-release) | YES | Capsule can be opened; contents suitable for tube use. |
Recommendation Summary:
[lab data]
2024-11-27 HBV DNA PCR Target Not Detected IU/mL
2024-10-08 HIV Ab-EIA Nonreactive
2024-10-08 Anti-HIV Value 0.06 S/CO
2024-10-07 HCV RNA PCR (quan) 4750000 IU/mL
2024-10-01 Anti-HBc Reactive
2024-10-01 Anti-HBc Value 2.29 S/CO
2024-10-01 Anti-HBs 68.29 mIU/mL
2024-10-01 EBV DNA (quan) 20100 IU/mL
2024-09-30 HBsAg Nonreactive
2024-09-30 HBsAg Value 0.34 S/CO
2024-09-30 Anti-HCV Reactive
2024-09-30 Anti-HCV Value 23.32 S/CO
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
He is a 58-year-old man with non-keratinizing undifferentiated nasopharyngeal carcinoma (NPC) initially staged cT4N3 with systemic risk (PET-avid liver/bone nodes) (pathology 2024-09-18; PET 2024-09-27). He received induction TPF (2024-10-01~2024-12-18) followed by CCRT with weekly cisplatin (2025-02-05~2025-03-26; RT 50–54 Gy) and now shows a stable primary tumor with regressing cervical nodes (MRI 2025-06-12). Current issues on 2025-08-31 include neutrophilic leukocytosis and inflammation (WBC 17.62 x10^3/uL, neutrophils 88.5%, CRP 5.99 mg/dL) while on Loforan (cefotaxime) and analgesics; microscopic hematuria without pyuria (UA 2025-08-31); elevated D-dimer (1093 ng/mL FEU) raising VTE concern; malnutrition markers remain low (albumin 2.9 g/dL, prealbumin 6.11 mg/dL on 2025-06-18). Bone disease remains possible (small rim-enhancing lesions at C6/T2 earlier; new osteopenic defect at left femoral greater trochanter) (MRI 2025-01-03 and 2025-06-12; X-ray femur 2025-06-18). HBV prophylaxis is in place with Baraclude (entecavir) and HBV DNA undetectable (2024-11-27); HCV RNA remains high (2024-10-07).
Problem 1. Suspected active infection / systemic inflammatory response (likely skin/soft tissue vs other source)
Problem 2. NPC status after induction TPF and CCRT (disease control and surveillance)
Problem 3. Possible skeletal metastasis and risk of pathologic fracture (not posted)
Problem 4. Malnutrition and weight trajectory (not posted)
Problem 5. Hematologic status (anemia improved; leukocytosis) (not posted)
Problem 6. Electrolyte and mineral abnormalities (mild) (not posted)
Problem 7. Microscopic hematuria (not posted)
Problem 8. Venous thromboembolism (VTE) risk (not posted)
Problem 9. Viral hepatitis management under oncology care (not posted)
Problem 10. Analgesia, sedation, and medication optimization (not posted)
Note (not posted)
Problem 11. Cardiometabolic and blood pressure/pulse control (not posted)
Follow-up Priorities (next 1–2 weeks)
This is a 58-year-old man with nasopharyngeal carcinoma (NPC), staged as cT4N3M1 (Stage IVC) due to intracranial extension and distant lymph node metastases (MRI 2024-09-26, PET 2024-09-27). Pathology confirms non-keratinizing undifferentiated NPC (WHO Type 2B) (2024-09-18). He underwent induction chemotherapy with TPF starting 2024-10-01 and transitioned to concurrent chemoradiotherapy (CCRT) with weekly cisplatin beginning 2025-02-03. Locoregional tumor remained stable on MRI (2025-06-12), with some lymph node regression. However, the clinical course is complicated by anemia, fluctuating liver function, hypoalbuminemia, weight loss, syncope episodes, and a new infected leg wound affecting treatment compliance.
Problem 1. Locally advanced nasopharyngeal carcinoma, cT4N3M1 (stage IVC)
Problem 2. Poor oral intake and malnutrition
Problem 3. Anemia
Problem 4. Elevated liver enzymes and viral hepatitis
Problem 5. Pain and insomnia
[HCV] (not posted)
While initiating direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection is standard of care, immediate initiation may not be the best choice in this patient’s current clinical context due to several integrated reasons:
In summary, delaying DAA is not due to negligence but a strategic prioritization of the patient’s acute oncologic and infection control needs. Reassessment should occur after nutritional and wound stabilization or once systemic cancer therapy pauses or completes.
[exam finding]
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Key insights / summary
Problem 1. Metastatic sigmoid colon adenocarcinoma on FOLFOX (C3D15)
Problem 2. Chemotherapy tolerance and nausea/vomiting (grade 1)
Problem 3. HBV reactivation risk on chemotherapy (Anti-HBc positive)
Problem 4. Macrocytic anemia, grade 1–2
Problem 5. Blood pressure control and cardiovascular status (not posted)
Problem 6. Thrombocytopenia history and current hemostasis (not posted)
Problem 7. Renal function and fluid–electrolyte status
Problem 8. Oxaliplatin-induced peripheral neuropathy risk (not posted)
Problem 9. Nutrition and functional status (not posted)
Problem 10. Gastrointestinal function: constipation prophylaxis (not posted)
Problem 11. Venous thromboembolism (VTE) risk (not posted)
Problem 12. Indwelling Port-A status (not posted)
Problem 13. Oncologic surveillance markers and imaging plan (not posted)
Current active medications of note (selected) (not posted)
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
The patient is a 67-year-old male with a history of esophageal squamous cell carcinoma (initially cT2N1M0, stage II, later ypT1aN2M0, stage IIIB after VATS esophagectomy on 2025-06-30), right vocal cord carcinoma (cT1aN0M0, stage I, post-laryngomicrosurgery on 2025-01-17), and a right frontal brain tumor (39 mm, differential diagnosis: glioblastoma multiforme vs metastasis).
He received chemoradiotherapy (2025-02 to 2025-04), liver biopsy (benign, 2025-05), and palliative RT to brain lesion (3960 cGy/12 fx, 2025-07-30 to 2025-08-14).
He was admitted on 2025-08-26 with fever, abdominal pain, jejunostomy leakage, and CT evidence of rim-enhanced lesion (2.6 cm) in lower abdomen suggesting abscess/urachal tumor. Current labs show anemia (Hgb 9.7 g/dL on 2025-08-27), elevated CRP (28.36 mg/dL on 2025-08-27), markedly elevated D-dimer (8131 ng/mL FEU on 2025-08-27), preserved renal function (Cr 1.0 mg/dL, eGFR ~79 mL/min/1.73m² on 2025-08-27), mild hypoalbuminemia (2.9 g/dL on 2025-08-11), and stable electrolytes.
He is on antibiotics (Tapimycin (piperacillin/tazobactam) + SABS (metronidazole) since 2025-08-28), supportive care (Bfluid, TPN, wound care), and multiple chronic medications. Vitals are stable but borderline hypotension and oxygen saturation dips (SpO2 as low as 77% on 2025-08-27). Current ECOG PS is 3.
Problem 1. Abdominal abscess / urachal lesion with UTI
Problem 2. Jejunostomy leakage and peristomal infection
Problem 3. Right frontal brain tumor (GBM vs metastasis) with mass effect
Problem 4. Anemia
Problem 5. Coagulation and thrombotic risk (new version, with infection context)
Problem 5. Coagulation and thrombotic risk (old version, not used)
Problem 6. Nutrition and metabolic status
Problem 7. Cardiopulmonary status
[lab data]
2024-10-01 Anti-HBc Reactive
2024-10-01 Anti-HBc-Value 5.39 S/CO
2024-09-30 Anti-HCV Nonreactive
2024-09-30 Anti-HCV Value 0.13 S/CO
2024-09-30 Anti-HBe Nonreactive
2024-09-30 Anti-HBe Ratio 1.08 S/CO
2024-09-30 HBsAg Nonreactive
2024-09-30 HBsAg Value 0.38 S/CO
[exam finding]
[MedRec]
2025-06-25 SOAP Metabolism and Endocrinology Hu YaHui
2025-05-01 ~ 2025-06-15 POMR Hemato-Oncology Xia HeXiong
2025-04-30 SOAP Metabolism and Endocrinology Hu YaHui
2025-04-15 ~ 2025-04-22 POMR Hemato-Oncology Xia HeXiong
2025-02-17 ~ 2025-04-04 POMR Hemato-Oncology Xia HeXiong
2025-01-13 ~ 2025-02-02 POMR Hemato-Oncology Xia HeXiong
[consultation]
2025-07-22 Dermatology
2025-05-22 Infectious Disease
2025-05-21 Dermatology
2025-04-18 Metabolism and Endocrinology
2025-04-15 Infectious Disease
2025-04-01 Infectious Disease
2025-03-26 Dermatology
2025-02-24 Ophthalmology
2025-02-19 Diagnostic Radiology
2025-02-18 Dermatology
2025-02-18 Infectious Disease
2024-12-17 Gastroenterology
2024-11-07 Urology
2024-09-30 Radiation Oncology
2024-09-30 Radiation Oncology
2024-09-30 Gastroenterology
[surgical operation]
[radiotherapy]
[chemotherapy]
Patient Summary
Problem 1. Metastatic esophageal SCC – systemic therapy + node-directed ablation
Problem 2. Thrombocytopenia under Revolade (eltrombopag)
Problem 3. Macrocytic anemia (chemotherapy-related vs nutritional vs disease)
Problem 4. Neutropenia risk and infection prophylaxis (not posted)
Problem 5. Hypomagnesemia (cisplatin-related)
Problem 6. Hepatic metastases, prior liver abscess (VRE), and HBV exposure prophylaxis
Problem 7. CBD stone without obstruction
Problem 8. Residual aortic dissection and hypertension
Problem 9. Renal function and nephrotoxin exposure (not posted)
Problem 10. Diabetes mellitus and steroid exposure (not posted)
Problem 11. Jejunostomy and port-A care (not posted)
Problem 12. Dermatologic and neuropathic symptoms (not posted)
Closing note
Key Insight / Summary
Problem 1. Thrombocytopenia
Problem 2. Macrocytic Anemia (not posted)
Problem 3. Esophageal Cancer, Stage IVB (T3N3M1b)
Problem 4. Nivolumab-Related Cutaneous Adverse Event
Problem 5. Chronic Liver Parenchymal Disease, Post-Abscess Status
Problem 6. Electrolytes and Renal Function (not posted)
Problem 7. Vital Signs and General Condition (not posted)
The patient, with stage IVB esophageal squamous cell carcinoma, remains under palliative chemotherapy with stable vital signs, no active fever, and stable BP control. Current medications include antihypertensives, antivirals, pain management, and supportive therapy. There is no active thrombopoietic agent such as “Revolade (eltrombopag)” prescribed presently.
Problem 1. Organ Functions and General Condition
Problem 2. Hematological Status
Problem 3. Electrolyte Management
Problem 4. Pain and Neuropathy Management
Problem 5. Antiviral and Metabolic Support
[older, not posted]
Problem 1. Organ Functions and General Condition
Problem 2. Hematological Status
Problem 3. Electrolyte and Metabolic Monitoring
Objective
Assessment
Recommendation
Problem 4. Pain and Neuropathy Management
Objective
Assessment
Recommendation
Problem 5. Antiviral Prophylaxis and HBV Status
Objective
Assessment
Recommendation
[Concor (bisoprolol) tube feeding]
Concor (bisoprolol) 5 mg immediate-release (IR) tablets are generally considered suitable for administration via a feeding tube using the simple suspension method. This method facilitates medication delivery for patients who are unable to swallow whole tablets.
Preparation using Simple Suspension Method (SSM):
Tube Administration Procedure:
[Summary]
The patient, a 62-year-old man with a history of esophageal squamous cell carcinoma (T3N3M1b, stage IVB) with metastases to the liver, spleen, and left supraclavicular lymph nodes, has been undergoing systemic chemotherapy with TPFL (docetaxel, cisplatin, fluorouracil, leucovorin) plus nivolumab since 2025-01-02. He recently completed C3 of TPFL on 2025-01-30 and underwent radiofrequency ablation (RFA) for liver metastases on 2025-01-24.
His course has been complicated by bacteremia (Escherichia coli, blood culture 2025-01-11), anemia, leukocytopenia, and thrombocytopenia, requiring supportive treatments including G-CSF (granulocyte colony-stimulating factor), eltrombopag, and transfusions. A recent CXR (2025-02-17) shows borderline cardiomegaly, prior sternotomy, and residual aortic dissection, while liver imaging confirms multiple hepatic metastases despite prior MWA (microwave ablation) and RFA.
Recent laboratory results indicate: - Persistent anemia (Hgb 9.2 g/dL, 2025-02-17) - Mild leukocytosis (WBC 7.47 ×10³/uL, 2025-02-17) but neutrophilia (93.3%) - Stable renal and hepatic function, but hypoalbuminemia (3.6 g/dL, 2025-02-17) - Iron deficiency (Fe 36 ug/dL, TIBC 313 ug/dL, 2025-02-17) - Mild hypokalemia (K 3.2 mmol/L, 2025-02-11)
His vital signs have shown episodic fever (max 38.9°C, 2025-02-17 12:44), tachycardia (HR 128 bpm, 2025-02-17 10:58), and fluctuating blood pressure (max 196/87 mmHg, 2025-02-17 10:47). These require close monitoring, especially given his history of aortic dissection.
[Problems]
Problem 1. Persistent Anemia (Multifactorial: Chemotherapy-Induced, Iron Deficiency, Chronic Disease)
Problem 2. Persistent Liver Metastases (Despite RFA & MWA, Ongoing Systemic Therapy)
Problem 3. Persistent Neutrophilia with Recent Bacteremia (Escherichia coli, 2025-01-11, ? Ongoing Infection/Inflammation)
Problem 4. Hypoalbuminemia (3.6 g/dL, 2025-02-17) with Cachexia
[Concor 5 mg Administration via Simple Suspension Method (SSM) for Tube Feeding]
For patients receiving enteral nutrition through a feeding tube, Concor 5 mg tablets can be conveniently administered using the Simple Suspension Method (SSM). This method involves crushing the tablet and dissolving it in warm water. After allowing the mixture to soak briefly, the suspension is ready for direct administration through the feeding tube.
Benefits of SSM:
[Assessment of Bowel Movements and White Blood Cell (WBC) Count]
Bowel Movement Patterns:
White Blood Cell (WBC) and Neutrophil Count (2024-11-05):
Recommendations
By addressing constipation proactively and monitoring neutrophil trends, these recommendations aim to mitigate common chemotherapy side effects and reduce infection risk during treatment.
[Clinical Course and Management of Advanced Esophageal Cancer]
Diagnosis and Presentation (2024-09-29)
Further Imaging and Findings (2024-10-07 to 2024-10-08)
Current Treatment: Chemoradiotherapy (2024-10-09 and 2024-11-05)
Progression and Labs
Consideration of Targeted Therapy
Supportive and Symptom Management
Ongoing Monitoring of Metastatic Sites
Comorbidity Management
The patient’s treatment plan aligns with aggressive systemic and local disease management strategies. A review of the patient’s medication history within HIS5 and PharmaCloud databases revealed no discrepancies.
[Concor 5mg Administration via Simple Suspension Method (SSM) - tube feeding]
For patients receiving enteral nutrition by use of a tube, Concor 5mg tablets can be easily administered using the SSM. This involves crushing the tablet and dissolving it in warm water. After a brief soaking period, the suspension can be directly administered through a feeding tube.
SSM offers several advantages:
[anti-HBc reactive: initiating prophylaxis with entecavir or tenofovir before immunosuppressive therapy]
Since the patient’s Anti-HBc is reactive, it is recommended to start Baraclude (entecavir) or Vemlidy (tenofovir alafenamide) prior to any immunosuppressive treatments (such as chemotherapy) as a prophylactic measure to prevent HBV reactivation.
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Subjective]
Nutritional intake
Treatment-related concerns
Emotional status
[Objective]
Nutritional/laboratory data
Hematology
Oncology status
Medication review
[Assessment]
Nutritional concern
Chemotherapy adverse effect monitoring
Medication appropriateness
Psychosocial support
[Plan / Recommendation]
Nutritional support
Chemotherapy safety
Medication management
Psychological care
The patient is a 76-year-old female with newly diagnosed right ovarian carcinosarcoma (biopsy 2025-08-08) with peritoneal carcinomatosis, bilateral malignant pleural effusion, and pulmonary metastases, staged IVB (cT3cN1M1b). She presented with abdominal fullness and dyspnea, with tumor markers markedly elevated (CA125 > 3500 U/mL, 2025-08-06; CA153 160.2 U/mL, 2025-08-06). Imaging confirmed ovarian mass, carcinomatosis, and pleural/lung involvement (CT 2025-08-01). Pathology confirmed carcinosarcoma with high-grade serous carcinoma and sarcomatous elements. She underwent laparoscopic biopsy (2025-08-08), repeated thoracocentesis and pigtail drainage for malignant effusion (2025-08-11, 2025-08-20), and Port-A insertion (2025-08-20). She received cycle 1 neoadjuvant Carboplatin + Paclitaxel (dose-reduced) on 2025-08-22 with supportive Fulphila (pegfilgrastim) prophylaxis. ECOG performance is 3, prognosis poor. Course complicated by hypoalbuminemia, chronic anemia, and recurrent effusion. She was discharged on 2025-08-26 in relatively stable but fragile condition.
Problem 1. Advanced ovarian carcinosarcoma with carcinomatosis and lung/pleural metastases
Problem 2. Malignant pleural effusion and dyspnea
Problem 3. Hematological problems: anemia and risk of myelosuppression
Problem 4. Hypoalbuminemia and nutritional concerns
Problem 5. Electrolyte and renal function monitoring
Problem 6. HBV prophylaxis
Problem 7. Cardiopulmonary reserve
[exam finding]
2025-11-04 CXR
2025-10-23 CXR
2025-10-14 Sonography - chest
2025-10-12 ECG
2025-10-02 Pathology - gallbladder
2025-09-19 MRA - brain
2025-09-18 Nerve Conduction Velocity, NCV
2025-09-15 Tc-99m MDP bone scan
2025-09-12 L-spine AP + Lat (including sacrum)
2025-09-11 ECG
[MedRec]
2025-11-06 MultiTeam - Palliative care
2025-10-17 MultiTeam - Social Service
2025-10-17 MultiTeam - Psycho-oncology
2025-09-30 MultiTeam - Social Service
2025-09-30 MultiTeam - Psycho-oncology
2025-09-10 ~ 2025-10-25 POMR General and Gastrointestinal Surgery Chen YenZhi
2025-08-27 MultiTeam - Psycho-oncology
2025-08-18 ~ 2025-09-05 POMR Hemato-Oncology Xia HeXiong
2025-07-19 ~ 2025-08-02 POMR Gastroenterology Su WeiZhi
2025-07-17, 2025-03-28, 2025-01-10 SOAP Urology Wu ShuYu
Key insights / summary (2025-11-06)
Problem 1. Acute hypoxemic pneumonia with sepsis risk
Problem 2. Advanced HCC with chronic cholestasis and prior biliary interventions
Problem 3. Severe protein-calorie malnutrition and sarcopenia risk
Problem 4. Cardiopulmonary strain and myocardial injury (type 2 MI likely)
Problem 5. Hematologic status and bleeding/thrombosis balance in cancer
Problem 6. Electrolyte–renal profile and acid–base status
Problem 7. Hepatitis B management in the context of HCC
Problem 8. Goals of care and palliative co-care
Addendum — Direct answers to your two earlier questions (grounded in the current MAR and data)
Current medication list (started 2025-11-05 unless noted):
[Pariet FC tube feeding]
Pariet (rabeprazole) is an enteric-coated tablet and is not designed for tube feeding. Consider prescribing oral formulations like Nexium (esomeprazole), Dexilant (dexlansoprazole), or Takepron (lansoprazole), which can be dissolved in water for tube administration.
Key Insight / Summary
Problem 1. Persistent conjugated hyperbilirubinemia after ERCP
Problem 2. Malignant biliary obstruction from HCC (external compression/infiltration)
Problem 3. Suspected biliary tract infection / acute cholecystitis, now clinically controlled but at risk
Problem 4. Biliary pancreatitis / pancreatic involvement, improved (not posted)
Problem 5. Advanced HCC with left portal vein thrombosis (BCLC C) affecting systemic therapy planning
Problem 6. Medication-related hyperbilirubinemia risk (which current drugs could increase bilirubin)
Problem 7. Chronic hepatitis B with very high viral load; antiviral on board
Problem 8. Coagulation and vitamin K (phytonadione) status in cholestasis (new version, not posted)
Problem 8. Coagulation and vitamin K status in cholestasis (old version, not posted)
Problem 9. Electrolyte disturbances (hypokalemia, borderline hypomagnesemia, low-normal calcium) (not posted)
Problem 10. Hematologic profile (anemia, thrombocytopenia risk) (not posted)
Problem 11. Peptic/duodenal ulcer disease and reflux esophagitis (not posted)
Problem 12. Cardiopulmonary status and peri-procedural risk (not posted)
Problem 13. Benign prostatic hyperplasia with bladder outlet obstruction (not posted)
Problem 14. Nutrition and functional status (not posted)
Problem 15. Glycemic status (not posted)
Problem 16. Pain, sleep, and comfort (not posted)
[exam finding]
[MedRec]
[consultation]
[Subjective]
Digestive tract status - Family (father side aunt) reported on 2025-08-27 that there is no current evidence of gastrointestinal bleeding - No hematemesis or melena described - NG feeding ongoing without intolerance
General condition - Patient remains weak and fatigued - Described as easily tired in daily activity - Oral intake not yet adequate, but NG feeding tolerated
Treatment discussion - Patient’s aunt noted concern from patient about adverse effects of chemotherapy - Expressed that chemotherapy-related toxicities are worrisome - Discussed possibility of using immunotherapy alone to reduce chemotherapy toxicity risk - Aunt will communicate with patient’s husband to bring up this point during next clinic visit
[Objective]
Recent clinical course - Discharged on 2025-08-23 after hospitalization for duodenal ulcer bleeding and bladder cancer complications - EGD (2025-08-19) showed duodenal ulcers with clean base (Forrest III), no active bleeding - Current weight on 2025-08-23: 55.4 kg - Albumin 2.8 g/dL (2025-08-20), still low - NG feeding currently functional and providing nutrition
Medication record - Nexium (esomeprazole 40mg) 1# QDAC - Gasmin (dimethylpolysiloxane 40mg) 1# TID - Smecta (diosmectite 3g) 1# PRN TIDAC - Kentamin (vitamin B1 50mg, vitamin B6 50mg, vitamin B12 500mcg) 1# QD - Tranexamic acid 250mg 1# BID - Through (sennoside 12mg) 2# HS - Promeran (metoclopramide 3.84mg) 1# BIDAC - Feburic (febuxostat 80mg) 0.5# QOD
[Assessment]
Gastrointestinal bleeding - No current re-bleeding symptoms per family report - EGD confirmed healing ulcers (2025-08-19) - On PPI therapy, condition stable
Nutritional status - NG feeding tolerated, but persistent fatigue and low albumin suggest ongoing malnutrition and systemic inflammation - Needs close monitoring to prevent further decline
Cancer treatment options - Patient has advanced urothelial carcinoma (stage IVB, pathology 2025-08-14) - Concern expressed about cytotoxic chemotherapy adverse events - Immunotherapy monotherapy (e.g., pembrolizumab) may provide disease-directed treatment with lower acute toxicity than chemotherapy - Decision should integrate goals of care, dialysis status, frailty, and family preference
[Plan / Recommendation]
Gastrointestinal protection - Continue high dose PPI (Nexium esomeprazole 40mg QDAC) - Avoid NSAIDs, maintain gastric protection - Monitor hemoglobin in outpatient follow-up
Nutrition - Continue NG feeding with gradual oral intake as tolerated - Consider nutritionist referral for high-calorie, high-protein plan - Monitor albumin trend; supportive supplementation if possible
Cancer treatment decision - Suggest discussing immunotherapy monotherapy with oncologist - May reduce chemotherapy-associated adverse effects - Suitable for ESRD patients without dose adjustment - Family to bring up treatment concerns at next oncology clinic visit
Supportive care - Continue ESA therapy with dialysis for anemia - Monitor fatigue, quality of life, and adjust medications accordingly - Coordinate with palliative care for symptom management and treatment alignment with patient preference
The patient is a 74-year-old female with advanced invasive urothelial carcinoma of the urinary bladder (stage IVB, T4aN3M1b) with local invasion into the uterine cervix, nodal metastases, peritoneal carcinomatosis, ascites, and bilateral hydronephrosis (CT 2025-08-01, MRI 2025-07-21, pathology 2025-08-14). She also has ESRD on regular hemodialysis (QW135) with progressive renal dysfunction (eGFR 20.29 mL/min/1.73m² on 2025-07-28 → 8.48 mL/min/1.73m² on 2025-08-20). Her course was complicated by recurrent duodenal ulcer bleeding requiring multiple EGDs and hemostatic interventions (2025-08-06, 2025-08-07, 2025-08-19), hypovolemic shock, coagulopathy, and MICU stay. She demonstrates persistent leukocytosis, anemia, and hypoalbuminemia, with recurrent infections (elevated CRP and PCT). Palliative direction has been discussed with emphasis on comfort care (family meeting 2025-08-20). Current functional status is frail with poor nutrition, anemia, and ESRD.
Problem 1. Invasive urothelial carcinoma of urinary bladder, stage IVB
Problem 2. End-stage renal disease with worsening renal function
Problem 3. Recurrent upper gastrointestinal bleeding due to duodenal ulcers
Problem 4. Anemia (multifactorial: GI bleed, ESRD, malignancy)
Problem 5. Infection and sepsis
Problem 6. Nutrition and hypoalbuminemia
Problem 7. Cardiopulmonary status
[Integrated cancer-treatment suggestions]
Context snapshot
Therapeutic stance
Step 0. Stabilize and prepare (before starting systemic therapy)
Path A (preferred if performance status allows): Padcev (enfortumab vedotin-ejfv) + Keytruda (pembrolizumab)
Path B (more conservative, if very frail or declining ADC): Keytruda (pembrolizumab) monotherapy
Path C (if immunotherapy contraindicated/unacceptable and cytotoxic therapy is desired): Gemzar (gemcitabine) + Paraplatin (carboplatin)
Local/palliative disease control (should run in parallel regardless of path)
Supportive and preventive measures (across all paths)
What to do next (concrete 1–2 week plan)
Summary
[exam finding]
[MedRec]
2025-08-21 SOAP Dermatology Liao ZeYuan
2025-08-08 SOAP Dermatology Liao ZeYuan
2025-07-23 SOAP Dermatology Liao ZeYuan
2025-07-15 SOAP Dermatology Liao ZeYuan
2025-07-09 SOAP Dermatology Liao ZeYuan
2025-07-04 SOAP Dermatology Liao ZeYuan
2025-06-27 ~ 2025-06-30 POMR Hemato-Oncology Gao WeiYao
2025-06-13 ~ 2025-06-16 POMR Hemato-Oncology Gao WeiYao
2025-05-27 SOAP Radiation Oncology
2025-04-24 ~ 2025-05-02 POMR Orthopedics Liu JiYuan
2024-08-20 ~ 2024-09-03 POMR Urology Cai YaoZhou
2024-05-16 ~ 2024-05-21 POMR Urology Cai YaoZhou
[radiotherapy]
[immunotherapy]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 55-year-old man with advanced squamous cell carcinoma of the upper to middle third esophagus complicated by tracheoesophageal fistula, liver metastasis, and cachexia. He underwent Port-A insertion and feeding jejunostomy on 2025-06-09, followed by concurrent chemoradiotherapy (paclitaxel/carboplatin + 50.4 Gy RT from 2025-06-25 to 2025-08-01). He is now admitted (2025-08-22) for further systemic chemotherapy. Current issues include persistent electrolyte disturbances (hyponatremia, hypokalemia, hypocalcemia), anemia, hypoalbuminemia, hepatic enzyme elevation, and weight loss. His ECOG PS is 3, with dependence on jejunostomy feeding. Recent labs (2025-08-25) show HGB 10.7 g/dL, Na 128 mmol/L, K 3.4 mmol/L, Ca 2.12 mmol/L, Albumin 2.6 g/dL, AST 45 U/L, ALT 59 U/L, PLT 450K/µL, WBC 8.33K/µL with neutrophil predominance. He remains oxygen-supported via nasal cannula but is hemodynamically stable.
Problem 1. Advanced esophageal squamous cell carcinoma with tracheoesophageal fistula, liver metastasis, and cachexia
Problem 2. Electrolyte imbalance (hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia) (not posted)
Problem 3. Anemia (chronic disease and treatment-related)
Problem 4. Hepatic dysfunction (transaminitis and hypoalbuminemia)
Problem 5. Pulmonary involvement (pneumonia history, hemoptysis, oxygen support)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
The patient, a 77-year-old male with stage IV colorectal adenocarcinoma and a complex treatment history, remains on biweekly Avastin + FOLFIRI (dose-reduced) with concurrent comorbidity management. Recent labs (2025-08-20) show stable renal function, controlled electrolytes, and mild transaminitis. Hematologically, normocytic anemia persists with gradual RBC decline. Urinalysis (2025-08-03) reveals hematuria, pyuria, and bacteriuria suggestive of possible subclinical or resolving UTI. Tumor markers remain elevated (CEA 81.48 ng/mL, CA 19-9 3819.67 U/mL on 2025-08-01), consistent with known metastatic disease. ECOG performance remains functional. No recent neutropenic fever or major organ compromise documented. Chemotherapy with supportive premedication (including atropine) continues regularly. No evidence of acute toxicity or deterioration requiring urgent modification.
Problem 1. Hepatic enzyme elevation
Problem 2. Normocytic anemia (not posted)
Problem 3. Urinalysis abnormalities (not posted)
Problem 4. Renal function (not posted)
Problem 5. Tumor marker elevation and disease status (not posted)
Problem 6. Electrolytes and nutrition (not posted)
This is a 70-year-old female with metastatic ascending colon adenocarcinoma (cT4aN2aM1c, stage IVc) involving liver, bone, adrenal glands, duodenum, and peritoneum. She has undergone multiple cycles of reduced-dose Avastin + FOLFIRI (latest on 2025-06-27), with recent presentations of hepatocellular injury (ALT/AST elevation), suspected stent dysfunction (biliary), and post-obstructive complications. She is also receiving symptom-directed supportive medications. Current concerns include liver enzyme elevation, biliary obstruction, infection risk, tumor burden progression, and polypharmacy in the context of age and performance status.
Problem 1. Hepatocellular injury and biliary obstruction (not posted)
Problem 2. Chemotherapy regimen and tolerability (Avastin + FOLFIRI)
Problem 3. Structural complications from tumor progression (biliary and ureteral obstruction) (not posted)
Problem 4. Vital signs monitoring and infection surveillance (not posted)
Problem 5. Polypharmacy and supportive medications
This is a 70-year-old woman with stage IVc ascending colon adenocarcinoma (cT4aN2aM1c) with liver, bone, adrenal gland, duodenum, peritoneal metastasis, obstructive jaundice (status post ERBD 2025-02-03), bilateral hydronephrosis (status post bilateral DJ stent insertion 2025-01-15), and ECOG 2. She has received Avastin (bevacizumab) + FOLFIRI chemotherapy (2025-02-14, 2025-03-05), palliative radiotherapy (C5-T1 spine 3000cGy/10fx, ampulla of Vater tumor 2000cGy/8fx), and port-A was clear on 2025-05-06. Currently stable for further chemotherapy, under magnesium sulfate and sodium bicarbonate infusion, with vital signs stable (BT 36.6°C, BP 148/80 mmHg, PR 104 bpm, SpO2 98% at 2025-05-06 12:22), urine culture showing gram positive cocci 1000 CFU/cc (2025-05-03).
Problem 1. Malignant neoplasm of ascending colon (stage IVc)
Problem 2. Renal dysfunction with bilateral hydronephrosis
Problem 3. Electrolyte imbalance (hypomagnesemia, metabolic acidosis)
Problem 4. Infection risk and urinary tract infection
Problem 5. Cardiopulmonary status (not posted)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 68-year-old female with recurrent myxoid liposarcoma involving pleural metastases, previously treated with multiple surgeries, radiotherapy (4500 cGy/25 fx to tumor bed), and chemotherapy. As of 2025-08-20, she has rising CA125 (now 82.6 U/mL), pleural effusion with exudative characteristics (TP 4.5 g/dL, LDH 145 U/L), and is functionally impaired post-chemotherapy with fluctuating cytopenias and ongoing GI and sleep disturbances. Updated NCCN Guidelines (Version 1.2025) necessitate revision of systemic treatment priorities, particularly favoring Trabectedin.
Problem 1. Recurrent Myxoid Liposarcoma with Pleural Metastases
Problem 2. Post-chemotherapy Cytopenia and Infection Risk (not posted)
Problem 3. Electrolyte and Renal Function Status (not posted)
Problem 4. Symptom Burden: GI, Sleep, Anxiety (not posted)
Problem 5. Pleural Effusion Monitoring and Symptom Impact
Bedside Visit: 2025-03-19, at approximately 11:50
Patient Status:
Assessment:
Additional Notes:
[Updated Insights]
Since the last review on 2025-03-10, the patient’s condition has evolved with notable hematologic changes, chemotherapy-related complications, and ongoing management of recurrent myxoid liposarcoma.
Problem 1. Severe Chemotherapy-Induced Myelosuppression (Neutropenia, Anemia, Thrombocytopenia)
Problem 2. Chemotherapy-Associated Gastrointestinal Toxicity (Nausea, Constipation, Abdominal Distension)
Problem 3. Cardiorenal Function Monitoring Post-Chemotherapy
Problem 4. Insomnia and Psychological Well-Being
Problem 5. Monitoring for Tumor Progression and Chemotherapy Response
Conclusion
Patient Evaluation
Problem 1. Recurrent Myxoid Liposarcoma (Left Retroperitoneal)
Problem 2. Post-Chemotherapy Hematologic and Organ Function Monitoring
Problem 3. Cardiovascular Status and Chemotherapy Risk
Problem 4. Recent Infection: Pneumonia and Toxicoderma (not posted)
Conclusion
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
This 62-year-old male with ESRD on hemodialysis (QW135), longstanding type 2 diabetes mellitus, and recently diagnosed dual primary malignancies - left lower lobe lung adenocarcinoma (cT4N0M1a, stage IVA) and nasopharyngeal carcinoma (cT1N0M0, stage I) - has undergone PCI for NSTEMI with complex coronary artery disease. He is currently receiving concurrent chemoradiation for his nasopharyngeal carcinoma and is pending further systemic therapy for lung cancer. His course has been complicated by electrolyte imbalances, anemia, fluctuating troponin levels, signs of pleural effusion, and central nervous system involvement. Multimodal monitoring is critical to coordinate oncologic therapy with cardiovascular, renal, metabolic, and hematologic optimization.
Problem 1. ESRD on hemodialysis with fluid-electrolyte instability
Problem 2. NSTEMI with complex coronary artery disease (not posted)
Problem 3. Stage IVA lung adenocarcinoma with brain and pleural involvement
Problem 4. Concurrent nasopharyngeal carcinoma undergoing RT
Problem 5. Diabetes with poor control and insulin resistance
Problem 6. Anemia and chronic inflammation
Problem 7. Hypertension with fluctuating BP control
This is a 62-year-old male with synchronous dual malignancies: (1) stage IIIA left lower lobe lung adenocarcinoma (T4N0M0) without actionable mutations or PD-L1 expression, and (2) early-stage (cT1N0M0) nasopharyngeal non-keratinizing carcinoma (WHO type II), both biopsy-confirmed. He also has end-stage renal disease (ESRD) on thrice-weekly hemodialysis (QW135), long-standing type 2 diabetes with chronic foot ulcer, and ischemic heart disease. Based on the 2025-06-13 radiation oncology evaluation, the treatment strategy is concurrent chemoradiotherapy (CCRT) for nasopharyngeal carcinoma and planned neoadjuvant chemotherapy ± pembrolizumab for lung cancer following port-A insertion. The patient is clinically stable (ECOG 1), with preserved LV function and manageable comorbidities.
Problem 1. Stage IIIA left lower lobe lung adenocarcinoma (T4N0M0)
Problem 2. Stage I nasopharyngeal carcinoma (non-keratinizing, WHO-2A)
Problem 3. End-stage renal disease (on hemodialysis QW135)
Problem 4. Type 2 diabetes mellitus with chronic foot ulcer
Problem 5. Hypertension and ischemic heart disease
[A detailed analysis on the timing of hemodialysis after cisplatin infusion, grounded in current evidence-based strategies] (not posted)
Timing of Hemodialysis Post-Cisplatin
Hydration and Nephroprotection
Recommendation Summary for ESRD & Cisplatin Patient
Clinical Implication for This Patient
Ref:
[A detailed analysis on whether “ESRD reduces insulin clearance,” with support from academic sources]
Mechanistic Basis
Clinical Evidence
Multiple reviews indicate that exogenous insulin clearance is diminished in advanced renal failure, with reduced dosage needs and prolonged insulin effect 3.
One source states: “In some patients with advanced insulin-dependent T2DM with ESRD, the insulin requirement becomes markedly reduced, in part due to decreased insulin clearance.” 3
A 2021 consensus noted kidneys responsible for 30–80 % of insulin clearance; decreased GFR prolongs insulin half-life 4.
Summary
Clinical Implication
Ref:
[MedRec]
[Subjective]
Medication use
[Objective]
Laboratory data
Medication records
[Assessment]
Glycemic control
Medication safety
Patient behavior
[Recommendation]
Medication adjustment
Monitoring
Patient education
[issues in the prescriptions]
Here are the main issues with the current prescription set when comparing across specialties and timepoints:
In short:
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
[Subjective]
Patient’s wife collected hemato-oncology clinic medications on 2025-08-18. Pharmacist identified loperamide and inquired about its use. Patient’s wife reported patient has severe diarrhea after chemotherapy.
Follow-up on 2025-08-20 today, patient stated:
Patient also confirmed awareness of regimen adjustment from Avastin + FOLFIRI to Avastin + FOLFOX. He was counseled on potential oxaliplatin toxicities such as peripheral neuropathy and instructed to report promptly if symptoms occur. Patient verbalized understanding.
[Objective]
[Assessment]
[Recommendation]
[exam finding]
[MedRec]
[Subjective]
Patient’s daughter visited on 2025-08-20 to inquire about the father’s medications.
[Objective]
Laboratory data:
Medication list:
Facility records: vital signs stable, body weight stable, SpO₂ ≥95%.
[Assessment]
Hypokalemia
Dyspnea sensation despite SpO₂ >95%
Medication safety
[Recommendation]
Hypokalemia management
Dyspnea management
Medication optimization
Family education
[Subjective]
Medication use inquiry
Caregiver response
[Objective]
Current cardiology prescription as of 2025-06-25 (28-day supply)
Laboratory data from 2025-06-18
Blood pressure trend
[Assessment]
Heart failure regimen adequacy
Polypharmacy and CNS medication concerns
Electrolyte monitoring
Statin double therapy
[Plan / Recommendation]
Patient/caregiver education and adherence support
Sedative use review
Electrolyte and renal function monitoring
Lipid management
The patient has heart failure with preserved renal function and recurrent hypernatremia, post-acute decompensated cardiac event (elevated hs-Troponin I up to 9049.1 pg/mL on 2025-05-26), now clinically stable on cardiology follow-up. Blood gases show trends of chronic respiratory acidosis with partial metabolic compensation. Recurrent borderline hypokalemia and persistent anemia are noted. Evidence of prior UTI with glucosuria and yeast on urinalysis (2025-05-26) likely reflects SGLT2 inhibitor effect but requires continued surveillance. The medication regimen includes appropriate heart failure and cardiovascular risk management, but the use of several agents affecting renal perfusion, blood pressure, and electrolytes necessitates close monitoring.
Problem 1. Heart failure with recent ischemic insult
Problem 2. Hypernatremia and fluid balance
Problem 3. Anemia
Problem 4. Renal function and nephrotoxic risk
Problem 5. Electrolyte imbalance (Hypokalemia, Hypocalcemia)
Problem 6. Chronic compensated respiratory acidosis
[Lipanthyl Supra (fenofibrate): an available alternative for gemfibrozil]
The gemfibrozil 600mg QD inquired about over the phone belongs to the ATC classification C10AB. A list of drugs in the same class is as follows. (https://atcddd.fhi.no/atc_ddd_index/?code=C10AB)
Our hospital has one available drug in this class, Lipanthyl Supra, where 1 tab of Lipanthyl Supra is approximately equivalent to 1g of gemfibrozil.
According to UpToDate, the significant adverse reactions of fenofibrate include hepatic effects, myopathy/rhabdomyolysis, photosensitivity, and renal effects. Although the incidence is low, these should still be monitored.
ATC code Name DDD U Adm.R Note Available - C10AB01 clofibrate 2 g
O
- C10AB02 bezafibrate 0.6 g O
- C10AB03 aluminium clofibrate
- C10AB04 gemfibrozil 1.2 g O
- C10AB05 fenofibrate 0.2 g O micronised Lipanthyl Supra FC (fenofibrate
160mg/tab) - C10AB06 simfibrate
- C10AB07 ronifibrate
- C10AB08 ciprofibrate 0.1 g O
- C10AB09 etofibrate
- C10AB10 clofibride
- C10AB11 choline fenofibrate 0.135 g O Refers to fenofibric acid -
C10AB12 pemafibrate
[lab data]
[exam finding]
[MedRec]
The patient is a 58-year-old male with severe aplastic anemia complicated by a small paroxysmal nocturnal hemoglobinuria (PNH) clone (3.9%). He underwent combined immunosuppressive therapy with Ciclosporin and Eltrombopag starting on 2025-07-14, but due to persistent pancytopenia, he subsequently received anti-thymocyte globulin (Thymoglobuline, rabbit ATG) from 2025-08-12 to 2025-08-15. He required recurrent transfusion support and showed severe hypocellularity on bone marrow biopsy (<5% cellularity, 2025-07-08). Cytogenetic testing revealed normal karyotype (46,XY, 2025-08-01). Recent labs showed persistent pancytopenia with risk of infection and hemorrhage. No acute hemolysis was observed. Imaging showed cardiac silhouette enlargement (CXR 2025-08-18) but preserved cardiac function (Echo 2025-07-04). The main issues are severe aplastic anemia, transfusion dependence, immunosuppressive treatment response evaluation, risk of infectious/hemorrhagic complications, and long-term consideration for allogeneic HSCT.
Problem 1. Severe aplastic anemia with pancytopenia
Problem 2. Risk of infection during profound neutropenia
Problem 3. Transfusion dependence and alloimmunization risk
Problem 4. Cardiac function and enlargement of cardiac silhouette
Problem 5. Renal and hepatic function monitoring under immunosuppression
[ChatGPT GPT-5 model comments on only lab results ended on 2025-08-19] (not posted)
Key insights / summary (integrated, time‑sequenced)
Problem‑oriented deliberation
What the physicians appear to be looking for (by test panels)
Differential diagnosis (ranked by descending likelihood)
Immediate data‑driven priorities
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
The patient is a 48-year-old female with stage IVa adenocarcinoma of the sigmoid colon (pT3N2aM1a, para-aortic lymph node metastasis) status post exploratory laparotomy with sigmoidectomy on 2025-07-17. She was admitted on 2025-08-18 for first cycle chemotherapy with FOLFIRI. Pathology confirmed moderately differentiated adenocarcinoma, MMR-proficient (PMS2, MSH2, MSH6, MLH1 intact), EGFR-positive, with 6/16 lymph nodes involved and extranodal extension. Clinical stage is at least IIIB, upstaged to IVa due to para-aortic node involvement (PET 2025-07-11, CT 2025-07-07). She has a background of resolved HBV infection (HBsAg negative, anti-HBc positive), now under Tenofovir alafenamide prophylaxis.
Recent labs (2025-08-18) show microcytic anemia (Hb 9.0 g/dL, MCV 69.6 fL, RDW 22.1%) and thrombocytosis (PLT 430 x10^3/uL). Renal and hepatic function remain preserved (Cr 0.64 mg/dL, eGFR 105, ALT 10 U/L, AST 13 U/L). Electrolytes stable with borderline low potassium (3.5 mmol/L). Vitals stable with ECOG PS 1. No acute abdominal or systemic symptoms. Current medications include Imperan (metoclopramide), Mosapride, saline infusion, and Vemlidy (tenofovir alafenamide).
Overall, the patient is clinically stable, tolerating chemotherapy initiation, but ongoing issues include anemia, risk of HBV reactivation, and the need for monitoring treatment response and complications.
Problem 1. Metastatic sigmoid colon adenocarcinoma (Stage IVa)
Problem 2. Anemia (likely iron deficiency, cancer-related)
Problem 3. HBV reactivation risk under chemotherapy
Problem 4. Electrolyte and nutritional status (not posted)
Problem 5. Supportive care and performance status (not posted)
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
The patient is a 56-year-old male with underlying cold autoimmune hemolytic anemia (post Rituximab on 2025-07-09, 2025-07-21, 2025-07-29), chronic ischemic heart disease, gout, and hyperlipidemia. He presented with shortness of breath since 2025-08-14 and was admitted on 2025-08-16 with pneumonia. Infectious workup showed negative influenza and COVID tests (2025-08-15), low procalcitonin 0.03 ng/mL (2025-08-15), and CRP 1.03 mg/dL (2025-08-15), suggesting a low-grade or atypical infection. CBC revealed leukopenia (WBC 2.83 x10^3/uL, 2025-08-15) with neutrophil predominance (76.7%), anemia (Hb 12.6 g/dL, Hct 37.4%, 2025-08-15) consistent with AIHA history, and platelets preserved (186 x10^3/uL, 2025-08-15). CXR reportedly showed bilateral mild infiltrations (2025-08-15). Oxygen saturation fluctuated 91–97% on room air with desaturation episodes to 92–93% (2025-08-15 to 2025-08-18). Current treatment includes Brosym (Cefoperazone/Sulbactam), Avelox (Moxifloxacin), steroids (Medason (Methylprednisolone), tapering), and supportive care. Main concerns:
Problem 1. Pneumonia with Mycoplasma pneumoniae infection (atypical pneumonia)
Problem 2. Autoimmune hemolytic anemia (AIHA) under Rituximab and corticosteroid
Problem 3. Leukopenia and infection risk
Problem 4. Cardiovascular comorbidity (ischemic heart disease, hyperlipidemia)
Problem 5. Electrolyte and renal function (not posted)
[allergy]
[lab data]
2025-06-04 HBsAg Nonreactive
2025-06-04 HBsAg Value 0.37 S/CO
2025-06-04 Anti-HBc Reactive
2025-06-04 Anti-HBc Value 4.91 S/CO
2022-12-13 Anti-HBc Reactive
2022-12-13 Anti-HBc Value 6.08 S/CO
2022-12-13 HBsAg Nonreactive
2022-12-13 HBsAg Value 0.33 S/CO
2022-12-13 Anti-HCV Reactive
2022-12-13 Anti-HCV Value 12.14 S/CO
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
Subjective
Objective
Assessment
Plan / Recommendation
The 77-year-old male patient with stage IV colorectal adenocarcinoma (descending colon pT3N0M0 and sigmoid pT2N0M0), KRAS/NRAS wild-type, has undergone multiple lines of chemotherapy (FOLFOX, A-FOLFIRI, A-FOLFOX), liver resections, and RFA for liver metastases. He is currently on Erbitux (cetuximab) + FOLFIRI regimen, with cycle #11 administered on 2025-08-13.
The patient continues to experience chemotherapy-related side effects, including fatigue, sensory neuropathy, constipation, and poorly controlled hyperglycemia. However, overall systemic condition remains stable without current signs of acute infection or hematologic toxicity. Vital signs and ECOG performance status remain acceptable (PS 1).
Problem 1. Hyperglycemia
Problem 2. Sensory Neuropathy
Problem 3. Fatigue and Constitutional Symptoms (not posted)
Problem 4. Constipation (not posted)
Problem 5. Blood Pressure Elevation
This 77-year-old male with stage IV descending and sigmoid colon adenocarcinoma (KRAS/NRAS wild-type) and chronic hepatitis B (anti-HBc positive, currently on Baraclude) continues palliative chemotherapy with FOLFIRI plus Erbitux. As of 2025-06-05, his liver and renal function remain preserved, and his hematologic profile is stable. He reports grade 2 peripheral sensory neuropathy and persistent constipation (G2) likely due to cumulative chemotherapy toxicity. No active infectious complications or severe systemic toxicity observed. Glycemic control is suboptimal post-chemotherapy (glucose range 112–202 mg/dL).
Problem 1. Advanced metastatic colorectal cancer (Erbitux + FOLFIRI regimen)
Problem 2. Peripheral neuropathy (Grade 2, chemotherapy-induced and diabetic-related)
Problem 3. Constipation (G2)
Problem 4. Chronic Hepatitis B (anti-HBc positive)
Problem 5. Type 2 Diabetes Mellitus (T2DM, suboptimal glycemic control)
Problem 6. Hematologic trend: stable mild thrombocytopenia (not posted)
Since the last review on 2025-01-02, the patient has undergone multiple chemotherapy cycles with cetuximab (Erbitux) + FOLFIRI, and laboratory monitoring indicates hematologic recovery but persistent thrombocytopenia. Liver and renal function remain stable, though BUN has increased. Blood glucose levels remain uncontrolled, showing significant postprandial spikes. Imaging findings indicate no recurrence in the colon but persistent metastatic liver disease with portal hypertension. Recent weight loss of 5 kg (from 81 kg on 2024-11-19 to 76 kg on 2025-03-18) suggests a need for further nutritional evaluation. The most pressing concerns include chemotherapy-related cytopenias, glycemic control, liver metastasis monitoring, and weight loss evaluation.
Problem 1. Chemotherapy-related cytopenia
Problem 2. Hyperglycemia (Uncontrolled Diabetes Mellitus)
Problem 3. Liver Metastases & Cirrhosis with Portal Hypertension
Problem 4. Weight Loss (5 kg Loss in 4 Months)
Problem 5. Blood Pressure Variability
Problem 6. Electrolyte & Renal Function Monitoring
Summary of Next Steps
[Patient Summary]
[Problem Comments]
Problem 1: Recurrent Liver Metastases with Suboptimal Treatment Response
Problem 2: Suboptimal Glycemic Control
Problem 3: Hypertension with Cardiovascular Risk
[managing high blood glucose during cancer therapy]
During this hospitalization, the patient has maintained stable vital signs and lab results from 2024-04-24 have been grossly normal. There is no contraindication to proceeding with this session of Erbitux plus FOLFIRI.
However, blood glucose levels have been recorded around 200 mg/dL, which remains elevated despite current medications, Relinide (repaglinide) and Galvus Met (vildagliptin, metformin). If these high glucose levels persist, the introduction of additional antihyperglycemic agents may be necessary.
[reconciliation]
There is no evidence in the lab results on 2024-04-01 to be a contraindication to the administration of chemotherapy.
[Baraclude (entecavir) dosage for reduced kidney function]
Renal function lab results:
2024-03-11 Creatinine 1.52 mg/dL
2024-02-27 Creatinine 1.26 mg/dL
2024-02-15 Creatinine 1.32 mg/dL
2024-01-31 Creatinine 1.03 mg/dL
2024-01-18 Creatinine 1.36 mg/dL
2024-01-10 Creatinine 1.11 mg/dL
2024-03-11 eGFR 47.63 ml/min/1.73m^2
2024-02-27 eGFR 59.14 ml/min/1.73m^2
2024-02-15 eGFR 56.05 ml/min/1.73m^2
2024-01-31 eGFR 74.63 ml/min/1.73m^2
2024-01-18 eGFR 54.15 ml/min/1.73m^2
2024-01-10 eGFR 68.45 ml/min/1.73m^2
On 2024-03-11, a serum creatinine level of 1.52 mg/dL was measured, indicating a slight decline in kidney function. For patients taking Baraclude (entecavir) with a CrCl between 30 and 50 mL/minute, the following dosage adjustments are recommended:
Medications prescribed by other departments are incorporated into the current medication list, and no discrepancies have been identified.
In addition to visiting our hemato-oncology department, the patient also consulted our urologist on 2023-07-07 and our cardiologist on 2023-07-14. The urologist prescribed Urief (silodosin) and the cardiologist prescribed Concor (bisoprolol). These medications were accurately added to the active formulary and no discrepancies were found during reconciliation.
According to the current PharmaCloud database, the patient refiled his prescription at Taipei City Hospital on 2023-06-21 for Algitab Chewable Tablets (alginic acid), Avamys Nasal Spray (fluticasone furoate), and Engene Eye Drops Patron (flavineadenine dinucleotide), all of which are valid for 28 days and are currently still valid. However, these medications are not yet on the patient’s active formulary at our hospital. This could lead to potential medication reconciliation discrepancies. It’s advisable for the primary care team to confirm whether these medications are still needed for the patient’s current clinical condition. If these medications are needed, they should be added to the patient’s active formulary accordingly.
Per the PharmaCloud database, this patient recently had an outpatient visit at Taipei City Hospital on 2023-05-24. He was prescribed Algitab, Broen-C, acetaminophen for oral use, and sulfamethoxazole eye drops for a 28-day duration. Most of these medications are intended to manage GI symptoms. Upon examination of the current medication list, equivalent therapeutic drugs have already been prescribed. Consequently, no issues were identified during the medication reconciliation process.
Based on the serum glucose level range of 288 mg/dL to 230 mg/dL, it appears that the patient’s underlying condition of type 2 DM is not well-controlled despite taking Galvus Met (vildagliptin + metformin) and Relinide (repaglinide). However, since there is no evidence of renal insufficiency (as of 2023-04-10 with Cre at 1.02mg/dL, eGFR at 75.67, and BUN at 21), the addition of Dibose (acarbose 100mg) 0.5# TIDAC is recommended if the high glucose level persists.
The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.
The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.
[exam finding]
[chemotherapy]
[exam finding]
[MedRec]
The patient is a 92-year-old female with advanced pancreatic tail adenocarcinoma, now stage IV with documented liver metastases and suspected left adrenal metastasis (CT 2025-07-23). Tumor marker CA-199 has shown a rapid and marked increase from 243.92 U/mL (2022-12-28) to 96,330 U/mL (2025-07-22), accompanied by CEA elevation to 78.820 ng/mL (2025-07-22). Imaging progression is clear: pancreatic tail mass enlarged from 1.9×3.5 cm (CT 2025-03-06) to 2.8×4.6 cm (CT 2025-07-23), with new or progressive liver metastases. Functional status is ECOG PS 3, with poor appetite, 10 kg weight loss over 6 months, and LUQ pain likely cancer-related. Multiple comorbidities include CAD with pacemaker, hypertension, bilateral carotid stenosis, history of esophageal achalasia s/p botox injection (2024-07-16), colon polyps s/p polypectomy, and epilepsy limiting medication options (cannot tolerate PPI, gaster, mopride). Current admission (2025-08-12) is for CT-guided liver biopsy; antiplatelet therapy (Plavix) held since 2025-08-11.
Problem 1. Advanced pancreatic tail adenocarcinoma with metastases
Problem 2. Nutritional decline and cancer cachexia
Problem 3. Comorbid cardiovascular disease with pacemaker
Problem 4. Epilepsy and medication intolerance
Problem 5. Chronic constipation (not posted)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
2025-07-21 - bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + docetaxel 50mg/m2 60mg NS 250mL + glutathione 1500mg/m2 2500mg NS 100mL 30min + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + fluorouracil 2600mg/m2 3100mg NS 500mL 24hr (Avastin + FLOT 70%. LV is missing)
2025-07-15 - Fruzaqla (fruquintinib 1mg) 4# QD self-paid purchase 84#
2025-07-01 - bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + docetaxel 50mg/m2 60mg NS 250mL + glutathione 1500mg/m2 2500mg NS 100mL 30min + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + fluorouracil 2600mg/m2 3100mg NS 500mL 24hr (Avastin + FLOT 70%. LV is missing)
2025-06-11 - bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + docetaxel 50mg/m2 50mg NS 250mL + glutathione 1500mg/m2 2500mg NS 100mL 30min + oxaliplatin 85mg/m2 90mg D5W 250mL 2hr + fluorouracil 2600mg/m2 2700mg NS 500mL 24hr (Avastin + FLOT 60%. LV is missing)
2025-05-16 - bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + docetaxel 50mg/m2 45mg NS 250mL + glutathione 1500mg/m2 2700mg NS 100mL 30min + oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + fluorouracil 2600mg/m2 2300mg NS 500mL 24hr (Avastin + FLOT 50%. LV is missing)
[note]
Systemic therapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) - 2025-06-11 - https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
Cycle length: 14 days.
Duration of therapy:
Regimen
This is a 68-year-old man with dual advanced malignancies: prostate adenocarcinoma (Gleason score 5+5, cT4N1M1b) with bone and urinary tract involvement, and rectal adenocarcinoma (cT3N2bM1) with liver metastasis. He is currently undergoing biweekly chemotherapy with Avastin + FLOT (docetaxel, oxaliplatin, fluorouracil, glutathione), now on cycle 3 day 1 (C3D1). The current admission (2025-08-11) was due to worsening dizziness, poor intake, anemia, and renal insufficiency. Evaluation reveals worsening anemia (HGB 7.9 g/dL), significant thrombocytopenia (PLT 73 x10^3/uL), hypoalbuminemia (2.7 g/dL), progressive azotemia (BUN 57 mg/dL, Cr 2.54 mg/dL, eGFR 26.86 mL/min/1.73m^2), and elevated inflammatory markers (CRP 5.68 mg/dL, PCT 1.12 ng/mL). He has poor oral intake and cachexia. Right-sided PCN is in place with pus, and DJ conversion is being evaluated. Overall, the patient is functionally PS 3, with signs of end-organ dysfunction requiring close monitoring, transfusion, and supportive care during chemotherapy.
Problem 1. Renal insufficiency with obstructive uropathy and AKI-on-CKD
Problem 2. Anemia and thrombocytopenia under cytotoxic chemotherapy
Problem 3. Advanced dual malignancy: prostate and rectal cancer with multi-organ metastases
Problem 4. Malnutrition and cachexia
Problem 5. Suspected indolent infection (UTI, possible bacteremia)
Problem 6. Fluid balance and hemodynamic fragility
The patient is a 69-year-old male with dual advanced malignancies: (1) rectal adenocarcinoma with liver metastasis (cT3N2bM1, stage IVb) and (2) prostate adenocarcinoma, Gleason 5+5 with bilateral ureteral invasion and bone metastasis (cT4N1M1b, stage IVb). He is undergoing biweekly Avastin + FLOT chemotherapy (C3D1 on 2025-07-01), with supportive care for chronic kidney disease (eGFR 30.4 mL/min/1.73m²), anemia (HGB 8.6 g/dL on 2025-06-30), hypomagnesemia (Mg 1.7 mg/dL), and persistent dysuria with bilateral PCN in place. Pain and appetite issues are mild. Chemotherapy tolerance remains acceptable (G1-G2 toxicities). Leucovorin was correctly added back into the FLOT protocol on 2025-07-01.
Problem 1. Renal Dysfunction with ESRD/CKD Progression
Problem 2. Anemia (Multifactorial: Marrow suppression, CKD, Cancer)
Problem 3. Active Cancer Therapy: Rectal Adenocarcinoma with Liver Metastasis
Problem 4. Prostate Adenocarcinoma with Bilateral Ureteral Invasion and Bone Metastasis
Problem 5. Infection Risk and Linezolid Use
Problem 6. Hypomagnesemia
Problem 7. Nutritional Support and Albumin
The 68-year-old male with dual primary malignancies—prostate adenocarcinoma (Gleason 5+5, cT4N1M1b) and rectal adenocarcinoma (cT3N2bM1) - is undergoing Avastin + FLOT chemotherapy since 2025-05-16. He also has chronic kidney disease secondary to obstructive uropathy and is complicated by recurrent urinary tract infections with bilateral percutaneous nephrostomies (PCNs) in place.
As of 2025-06-11, he tolerated chemotherapy without acute toxicity, though residual infection indicators and persistent anemia are noted. Chemotherapy continues without leucovorin; nephrology and infectious disease consultations are active.
Problem 1. Renal dysfunction and obstructive uropathy
Problem 2. Recurrent urinary tract infections (UTIs)
Problem 3. Chemotherapy regimen and response
Problem 4. Anemia of chronic disease and chemotherapy
Problem 5. Electrolyte and acid-base disturbance
This 68-year-old male with dual advanced malignancies—prostate adenocarcinoma (Gleason 5+5, cT4N1M1b) and rectal adenocarcinoma (cT3N2bM1) - presents with progressive disease complicated by bilateral obstructive uropathy, chronic kidney disease (Cr 1.79 mg/dL, eGFR 40.3 mL/min/1.73m² on 2025-05-15), anemia (Hb 6.9 g/dL), ongoing urinary tract infection (UTI) with pyuria and bacteriuria, and persistent inflammation (CRP 17.8 mg/dL on 2025-05-05, Procalcitonin 0.70 ng/mL on 2025-05-15). He planned to receive immunochemotherapy with Avastin + modified FLOT on 2025-05-16. There are signs of general skin itching and lower extremity edema (2+). He is being treated with empirical ceftriaxone and symptomatic management.
Problem 1. End-stage renal disease with obstructive uropathy and AKI episodes
Problem 2. Urinary tract infection with pyuria and bacteriuria
Problem 3. Anemia and inflammation
Problem 4. Advanced malignancies: Prostate and rectal cancer with metastases
Problem 5. Skin pruritus and peripheral edema
[Treatment Assessment] (not posted)
Here is a comprehensive and integrative assessment of the immunochemotherapy regimen administered on 2025-05-16, including commentary based on NCCN Guidelines (Rectal and Prostate Cancer, 2025) and clinical pharmacology principles:
Treatment Administered (2025-05-16):
Premedications:
Notable:
A. Integrated Commentary
This regimen combines anti-angiogenic therapy (bevacizumab) with a modified FOLFOX (fluorouracil + oxaliplatin) backbone and adds docetaxel, typically seen in triplet regimens like FLOT or DCF for GI cancers. The addition of glutathione, though non-standard, may reflect an attempt to mitigate oxaliplatin-induced neurotoxicity. However, evidence of glutathione’s clinical benefit remains inconclusive.
Given the combination and dosing intensity, this resembles a “modified triple-drug induction strategy”, potentially for a gastrointestinal malignancy such as advanced/metastatic rectal or gastric cancer with curative or conversion intent.
B. Evaluation Against Guidelines
Guideline alignment: While not a guideline-standard combination, this regimen reflects a real-world, patient-adapted protocol possibly used in a high-risk GI cancer scenario (e.g., unresectable rectal cancer, peritoneal mets, etc.).
Appropriate antiemetic and premedication strategy.
C. Recommendations/Suggestions
D. Overall Assessment
This combination reflects an aggressive but tailored regimen, probably designed with conversion to surgery or response maximization in mind. However, its deviation from NCCN-recognized regimens — particularly missing leucovorin and unvalidated use of glutathione — warrants close monitoring and potentially further refinement toward more evidence-based frameworks.
[exam findings]
2025-08-11 CXR
2025-08-06 Nasopharyngoscopy
2025-07-18 CT - abdomen
2025-07-17 Transrectal Ultrasound of Prostate, TRUS-P
2025-07-16 Tc-99m MDP
2025-05-21 CT - abdomen
2025-02-26 PET
2025-02-14 CT - abdomen
2024-10-09 CXR
2024-09-02 CXR
2024-08-27 Pathology - pancreas total/subtotal resection
2024-08-22 Doppler color flow mapping
2024-08-21 PET
2024-08-20 PTCD (percutaneous transhepatic cholangio drainage)
2024-08-20 Patho - duodenum biopsy
2024-08-20 Flow volume chart
2024-08-19 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-08-16 CT - abdomen
2024-08-15 ECG
2024-08-01 Patho - colon biopsy
2024-07-31 Colonoscopy
2024-07-29 Pathology Level IV
2024-07-29 Pathology Level IV
2024-07-26 Esophagogastroduodenoscopy, EGD
2024-07-24 CXR
2024-07-24 ECG
2024-01-08 ECG
2000-05-19 SONO - nephrology
2019-12-26 Doppler color flow mapping
2017-01-05 ECG
[MedRec]
[surgical operation]
[chemotherapy]
2025-07-29 - NS 50mL 15min + OBI-992 8mg/kg 688.8mg NS 181.1mL 3hr + NS 30mL 5min + NS 250mL 30min
2025-05-14 - fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-04-08 - fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-02-18 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-02-05 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-01-22 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-01-08 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2024-12-11 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2024-11-27 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2024-11-27 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2024-11-04 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr (Y-sited Covorin) + leucovorin 400mg/m2 800mg NS 250mL 1.5hr (Y-sited Irino) + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 500mL 48hr
2024-10-18 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + irinotecan 150mg/m2 300mg D5W 250mL 1.5hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 400mg/m2 800mg NS 100mL 10min + fluorouracil 2400mg/m2 4800mg NS 500mL 46hr
[note]
Systemic therapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2025-08-12 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Systemic therapy regimens for pancreatic cancer: Modified FOLFIRINOX - 2025-08-12 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
The patient is a 64-year-old male with a history of Stage IV adenocarcinoma of the ampulla of Vater, previously treated with Whipple surgery (2024-08-26) and FOLFIRINOX (2024-10-18 to 2025-05-16), currently on an investigational agent OBI-992 (first dose 2025-07-29). He was admitted on 2025-08-11 with neutropenic fever and pneumonia, presenting with progressive sore throat, fever up to 39.3°C, and cough. On admission, he had WBC 1.49k with bandemia (35%), anemia (Hb 8.5 g/dL), thrombocytopenia (PLT 60k), and elevated CRP (27.12 mg/dL). Imaging showed left lower lung consolidation. He is on broad-spectrum antibiotics (Tapimycin), G-CSF (Granocyte), nutritional support, and opioid analgesia for mucositis-related pain. On 2025-08-12, blood glucose was 366 mg/dL, likely stress- and steroid-related, requiring glycemic management. Renal function showed mild impairment (Cr 1.58 mg/dL, eGFR 47.02 mL/min/1.73m²). Overall, he remains hemodynamically stable but with ongoing pain, hyperglycemia, and immunosuppression.
Problem 1. Neutropenic fever with pneumonia
Problem 2. Oral mucositis with severe pain
Problem 3. Hyperglycemia
Problem 4. Anemia and thrombocytopenia
Problem 5. Mild renal impairment (not posted)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Subjective]
antiplatelet therapy adherence and bleeding concern
hepatitis B risk during chemotherapy
biliary tree evaluation
[Objective]
antiplatelet use and cardiovascular history
HBV serology (2025-05-12)
biliary imaging and labs
[Assessment]
antiplatelet management
HBV reactivation risk
biliary tract findings
[Plan / Recommendation]
antiplatelet therapy
HBV prophylaxis
biliary tree follow-up
The patient is a 70-year-old male with sigmoid colon adenocarcinoma, stage IIIB (pT3N1aM0), status post SILS anterior resection on 2025-05-12, currently receiving adjuvant mFOLFOX6 chemotherapy with a 25% dose reduction due to prior grade 3 diarrhea. Recent admission (2025-08-07) was for the third course of chemotherapy, with transient watery diarrhea episodes (2–3 times) on 2025-08-10 resolving spontaneously by 2025-08-11. Abdominal CT (2025-08-11) showed postoperative changes, benign liver/renal cysts, mild aortic dilatation, and gallstones, without acute obstruction or recurrence. Cardiovascular comorbidities include CAD s/p PCI (2025-03-23), hypertension, and hyperlipidemia, currently hemodynamically stable with appropriate pharmacologic control. Renal function on 2025-08-05 showed mildly reduced eGFR (57.49 mL/min/1.73m²) with stable electrolytes. Hematologic parameters were within acceptable limits for chemotherapy continuation. No signs of infection were noted.
Problem 1. Sigmoid colon adenocarcinoma, stage IIIB, post-SILS, on adjuvant mFOLFOX6
Problem 2. Post-chemotherapy diarrhea (grade 1, resolved)
Problem 3. Coronary artery disease, s/p PCI with DES (2025-03-23), on dual antiplatelet therapy
Problem 4. Mildly reduced renal function (not posted)
Problem 5. Gallstones and mild abdominal aortic dilatation (not posted)
This 70-year-old male has a confirmed diagnosis of moderately differentiated sigmoid colon adenocarcinoma (pT3N1aM0, AJCC stage IIIB) based on resection pathology dated 2025-05-13. He underwent single-incision laparoscopic anterior resection (SILS) on 2025-05-12 with negative resection margins and one of twenty mesocolic lymph nodes positive for metastasis. Notably, the patient also has significant cardiovascular comorbidity: he experienced acute anterior STEMI with triple vessel disease and underwent successful primary PCI with DES for proximal-to-mid LAD on 2025-03-23. He remains on dual antiplatelet therapy and cardiovascular medications. Lab data postoperatively are mostly stable; however, he is seropositive for anti-HBc, indicating prior HBV exposure. Planning for adjuvant chemotherapy (mFOLFOX6) is underway.
Problem 1. Stage IIIB sigmoid colon adenocarcinoma s/p resection
Problem 2. Coronary artery disease with TVD s/p anterior STEMI and PCI
Problem 3. Chronic HBV exposure (anti-HBc reactive)
Problem 4. Renal function and electrolyte trend
Problem 5. Liver function and biliary tree abnormality
[exam finding]
2025-08-07 ECG
2025-07-08 CXR
2025-07-02 PET
2025-07-02 Sonography - abdomen
2025-07-01 MRI - nasopharynx
2025-06-30 CXR
2025-06-26 Miniprobe Endoscopic Ultrasound
2025-06-26 Nasopharyngoscopy
2025-06-13 MRI - shoulder joint
2025-06-05 Pathology - tonsil biopsy
2025-05-30 Nasopharyngoscopy
2025-04-17 2D transthoracic echocardiography
2024-12-18 ECG
2024-09-06 L-spine flex & ext (including sacrum)
2024-09-06 KUB
2024-07-02 MRI - shoulder joint
2024-06-21 Shoulder Lt
2024-03-01 C-spine flex & ext view
2024-03-01 Nasopharyngoscopy
2024-01-09 MRI - kidney, adrenals
2023-08-31 uroflowmetry
2023-08-31 Miniprobe Endoscopic Ultrasound
2023-08-25 KUB
2023-08-25 L-spine flex & ext (including sacrum)
2023-03-03 CT - abdomen
2022-11-25 ECG
2022-11-15 Pathology - kidney partial/total resection
2022-11-13 ECG
2022-10-27 Pathology - prostate needle biopsy
2022-10-26 CT - abdomen
2022-10-24 Kidney Sonography - Urology
2022-10-19 MRI - prostate
2022-09-19 Transrectal Ultrasound of Prostate, TRUS-P
[MedRec]
2025-07-23 SOAP Gastroenterology Su WeiZhi
2025-06-30 ~ 2025-07-02 POMR Ear Nose Throat Huang TongCun
2025-05-16, 2025-02-21 SOAP Neurology Dai BoAn
2025-05-16, 2025-02-21 SOAP Cardiology Xie JianAn
2024-12-18 ~ 2024-12-21 POMR Lin KuenHui
2022-11-13 ~ 2022-11-18 POMR Urology Cai YaoZhou
出院診斷 1: Neoplasm of uncertain behavior of left kidney 2: Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent 3: Enlarged prostate with lower urinary tract symptoms
主 述 Admitted for left kidney excision and bilateral hernia repair on 11/14
病 史 This is a 76-y/o male with past history of
1.Cervical,lumbar spine HIVD s/p operation 2.left shoulder s/p operation 3.gallstone s/p operation 4.BPH,s/p biopsy
This time,his left kidney tumor was noted in health examination last year,but was found enlareged in OPD follow up.Bilateral inguinal hernia was also found.As a result,surgery for left kidney tumor excision and bilateral hernia repair were suggested.Under the impression of left renal tumor and bilateral inguinal hernia,he was admitted for scheduled operation of RAPN and LESS TEP on 111/11/14.
住院治療經過 After admission,pre-op evaluation was performed and the patient was okay to receive the surgery. Left kidney RAPN and bilateral TEP was performed on 11/14.After the operation,the patient’s clincal conditions was getting better day by day. There was no complication after the operation.Due to his stable clinical conditions,he was discharged today,and would kept OPD follow up on 11/24.
[consultation]
[surgical operation]
[immunochemotherapy]
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is an 81-year-old male with poorly differentiated adenocarcinoma of the gastric antrum, AJCC stage IIIB (pT4aN3a, cM0), status post laparoscopic radical subtotal gastrectomy with D2 lymph node dissection on 2024-09-09. He also has a history of invasive high-grade urothelial carcinoma of the urinary bladder (stage IIIA) s/p chemoradiotherapy, and chronic hepatitis B (anti-HBc positive). He is currently on adjuvant FOLFOX (20% dose reduction due to age), having completed C6D1 on 2025-07-08 and admitted for C6D15 on 2025-08-07.
Recent abdominal CT (2025-06-25) shows no evidence of tumor recurrence. Tumor markers are stable with CEA decreasing from 5.820 ng/mL (2025-04-11) to 3.840 ng/mL (2025-08-01), and CA 19-9 decreasing from 19.330 U/mL to 17.960 U/mL in the same period.
Laboratory data on 2025-08-07 revealed mild anemia (Hgb 11.4 g/dL), mild thrombocytopenia (PLT 122 ×10³/μL), CKD stage 3a (eGFR 50.04 mL/min/1.73m²), hypokalemia (K 3.2 mmol/L), and borderline low magnesium (1.8 mg/dL). He also presents with acute gout flare (right knee, bilateral ankles) and mild right scapular pain. Performance status ECOG 1.
Problem 1. Gastric adenocarcinoma, pT4aN3a, cM0, stage IIIB, post subtotal gastrectomy, on adjuvant chemotherapy
Problem 2. Chronic kidney disease stage 3a (not posted)
Problem 3. Acute gout flare with chronic hyperuricemia
Problem 4. Chemotherapy-related cytopenias (anemia, thrombocytopenia)
Problem 5. Electrolyte abnormalities – hypokalemia and borderline hypomagnesemia
This is an 80-year-old male with a history of stage IIIB gastric adenocarcinoma (pT4aN3a cM0) status post laparoscopic radical subtotal gastrectomy (2024-09-09) and concurrent high-grade invasive urothelial carcinoma (cT4aN0M0) of the bladder, previously treated with definitive chemoradiotherapy. He is currently undergoing adjuvant chemotherapy with FOLFOX (20% dose reduction due to age), and just started C5D1 (2025-05-19 to 2025-05-21). Recent labs indicate stable renal function (Cr 1.26 mg/dL, eGFR 58.38 mL/min/1.73m² on 2025-05-19), persistent normocytic anemia (HGB 10.8 g/dL), resolved thrombocytopenia, and normal liver enzymes. Tumor markers CEA and CA-199 remain within moderate range. His current ECOG PS is 1, with no reported GI complaints or systemic symptoms. He remains hemodynamically stable. Comorbidities including chronic HBV (anti-HBc+) and hyperuricemia/gout are under treatment.
Problem 1. Gastric Adenocarcinoma pT4aN3a cM0, stage IIIB
Problem 2. Myelotoxicity and Normocytic Anemia
Problem 3. Renal Function and Chemotherapy Safety
Problem 4. Cardiovascular and Perfusion Risk (not posted)
Problem 5. Bladder Cancer Surveillance Post-CCRT
This is a complex, elderly male patient with a history of advanced gastric adenocarcinoma (pT4aN3aM0, stage IIIB) status post subtotal gastrectomy with D2 LN dissection (2024-09-09) and concurrent invasive high-grade urothelial carcinoma (cT4aN0M0, stage IIIA) managed with pelvic RT + platinum-based chemotherapy. Currently, the patient is undergoing FOLFOX chemotherapy with a 20% dose reduction due to age. On 2025-03-28, he is clinically stable (ECOG PS 1) with no abdominal pain, tolerating intake, and passing diarrhea the day before. His recent labs show stable renal and liver function, normonatremia, hypocalcemia (2.12 mmol/L on 2025-03-27), and mild normocytic anemia (HGB 10.6 g/dL) with thrombocytopenia (PLT 101 x10³/uL). Surveillance tumor markers (CEA, CA-199) have shown slight fluctuation but remain within a moderate range. Recent imaging revealed stool impaction (KUB 2025-03-27) and increased lower lung markings (CXR 2025-03-27), which requires clinical correlation. The patient has a complex oncologic and cardiovascular background, including atherosclerosis, paroxysmal atrial fibrillation, left vocal cord palsy, and prostate hyperplasia.
Problem 1. Advanced Gastric Adenocarcinoma (pT4aN3aM0, stage IIIB)
Problem 2. Invasive High-Grade Urothelial Carcinoma of Bladder (cT4aN0M0, stage IIIA)
Problem 3. Renal Function and Chemotherapy Safety
Problem 4. Hematologic Status
Problem 5. Cardiovascular Comorbidity
[exam finding]
[consultation]
[surgical operation]
[chemotherapy]
This is a 56-year-old female diagnosed with bilateral ovarian endometrioid adenocarcinoma, FIGO stage IC (pT1c3N0) and concurrent endometrial adenocarcinoma, FIGO IA2, post-debulking surgery on 2025-02-24. She is currently undergoing adjuvant chemotherapy with paclitaxel/carboplatin, having received C1 on 2025-04-18 and admitted for C2 on 2025-05-13. She remains clinically stable (ECOG PS 1) with normalized tumor markers and recovered hematologic profile. No current signs of infection, organ dysfunction, or chemotherapy-related toxicity were identified.
Problem 1. Bilateral ovarian endometrioid adenocarcinoma, pT1c3N0, FIGO stage IC, post-debulking and adjuvant chemotherapy
Problem 2. Chemotherapy-related myelosuppression (resolved)
Problem 3. Liver and renal function under chemotherapy
[Subjective]
Medication use and adherence
Lifestyle and symptom concerns
[Objective]
Cardiovascular status
Laboratory data
Medications (2025-08-01)
[Assessment]
Heart failure and CAD management
Alcohol consumption concern
Insomnia management
Fish oil supplementation
[Plan / Recommendation]
Medication adherence
Lifestyle advice
Monitoring and follow-up
Patient education
病人及其太太和女兒前來診間,我向病人解釋每種藥物的用法,並且強調遵囑的重要性,病人詢問可不可以喝酒,睡不著怎麼辦?可不可以吃魚油?我回答病人說目前處方並無適應症為助眠的藥物,可以與醫師討論是否開立安眠藥物,此外應避免飲酒,又現在飲食很少有營養不足的狀況,魚油並非必要。
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Subjective]
treatment-related symptoms after C1D1 (2025-07-23) and C1D15 (2025-07-30) carboplatin plus etoposide
patient education and counseling
[Objective]
lab results
current medications
[Assessment]
treatment-related toxicities
renal function decline
hematologic
[Plan / Recommendation]
chemotherapy monitoring and supportive care
病人在二次化學治療 session 後目前的狀況是疲憊,爬樓梯會喘,食慾變得比較不好,但是沒有噁心嘔吐, 將病人介紹 carboplatin, etoposide 的可能不良反應請病人留意自身狀況,並注意腎功能狀況。
[exam finding]
[MedRec]
[consultation]
Key Insight / Summary
Problem 1. Multiple Myeloma (lambda light chain)
Problem 2. Chronic Kidney Disease with Recent Acute on Chronic Injury
Problem 3. Anemia
Problem 4. Infection Risk / Suspected Infection
Problem 5. Cardiovascular Disease and Hemodynamic Monitoring (not posted)
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
This is a 58-year-old woman with:
Problem 1. Right breast cancer (Stage IIB, ER+/PR+/HER2-, Ki-67 high)
Problem 2. Hepatic dysfunction and NAFLD/NASH (non-cirrhotic)
Problem 3. Hematological status during chemotherapy (not posted)
Problem 4. Glucose control and prediabetes (not posted)
Problem 5. Cardiac function under anthracycline-based chemotherapy
[exam finding]
[MedRec]
[Subjective]
medication adherence and tolerance
physical rehabilitation engagement
blood pressure and heart rate
revascularization plan
[Objective]
vital signs and labs
current pharmacotherapy
[Assessment]
dual antiplatelet therapy status
guideline-directed HFrEF regimen
lipid control
gout and uric acid management
GI and renal protection
[Plan / Recommendation]
optimize cardiovascular protection
lipid management
glycemic and renal monitoring
medication education
This 67-year-old male with a history of epilepsy, type 2 diabetes, and gout experienced an acute coronary syndrome on 2025-05-26 and was diagnosed with non-ST-elevation myocardial infarction (NSTEMI) with heart failure with reduced ejection fraction (HFrEF, LVEF 33%). He underwent successful PCI to the LAD (2025-06-03), with planned staged PCI to OM-1. Imaging and labs confirmed dual vessel CAD and anterior wall infarction. He has since been on dual antiplatelet therapy and optimized guideline-directed medical therapy for HFrEF, with gradual symptomatic improvement. The patient is undergoing cardiopulmonary rehabilitation and is scheduled for further revascularization.
Problem 1. Coronary artery disease (CAD), dual vessel with incomplete revascularization
Problem 2. Heart failure with reduced ejection fraction (HFrEF)
Problem 3. Type 2 diabetes mellitus
Problem 4. Gout and hyperuricemia
Problem 5. Renal function and proteinuria
[exam finding]
[MedRec]
[Subjective]
Respiratory medication technique
Medication adherence and tolerance
[Objective]
Medication in use
Recent status
[Assessment]
Inhaler technique improvement
Medication adherence and tolerability
[Plan / Recommendation]
Respiratory medication support
Adherence monitoring
Medication review opportunity
[exam finding]
[MedRec]
[radiotherapy]
[Subjective]
patient background and medication use
concerns and symptoms
[Objective]
renal function assessment
oncologic status
hematologic and hepatic function
[Assessment]
renal safety of abemaciclib
oncologic control
tamoxifen-related side effects
[Plan / Recommendation]
renal monitoring and education
hormonal and targeted therapy
This is a 43-year-old premenopausal female with right-sided hormone receptor-positive (ER > 90%, PR > 90%), HER2-negative (FISH-) invasive ductal carcinoma, pT1cN0(sn)cM0, status post breast-conserving therapy (BCT) and sentinel lymph node biopsy (SLNB) on 2023-09-13, followed by adjuvant radiotherapy and endocrine therapy with tamoxifen since 2023-10-03. She is also receiving the CDK4/6 inhibitor Verzenio (abemaciclib) 200 mg QHS (self-paid). Currently, there is no evidence of recurrence based on recent labs and imaging (e.g., CA153 22.010 U/mL, CEA 3.640 ng/mL on 2025-07-29; benign gynecologic sonography on 2025-04-21; bone scan negative on 2024-01-09). She experiences hot flushes and mild renal function fluctuation attributed to abemaciclib. The patient is in complete remission and continues on maintenance endocrine and targeted therapy.
Problem 1. Hormone receptor-positive, HER2-negative breast cancer (stage IA, pT1cN0)
Problem 2. Hot flushes and vasomotor symptoms from tamoxifen
Problem 3. Abemaciclib-induced renal function fluctuation
Problem 4. Gynecologic surveillance in tamoxifen user
[Treatment Course vs. NCCN Guidelines (2025)]
Conclusion
[MedRec]
The patient is a 63-year-old woman with gastric antral adenocarcinoma, post-subtotal gastrectomy (2025-06-09), staged pT3N1M0 with 1/48 lymph node involvement and HER2-negative status. She has received adjuvant chemotherapy and is being evaluated for nivolumab initiation. Clinical status remains stable with controlled comorbidities and no active infection or organ dysfunction. Current conditions support the initiation of immunotherapy. Three key problems are discussed below: immune checkpoint therapy eligibility, cardiovascular-autonomic instability, and glucose metabolism.
Problem 1. Immunotherapy Eligibility and Timing
Problem 2. Hemodynamic Instability / Orthostatic Trend (not posted)
Problem 3. Glycemic Fluctuation (Steroid-related and/or Diabetes) (not posted)
Since the last review on 2025-02-20, the patient has undergone chemotherapy (on 2025-02-20, 2025-03-10), and was admitted on 2025-03-18 for Nivolumab.
Problem 1. Adenocarcinoma of Gastric Antrum, cT3N2M0, Stage III (ECOG 1)
Problem 2. Recent Urinary Tract Infection (UTI) with Escherichia coli (this item not posted)
Problem 3. Post-Stroke Neurologic Recovery (Right Parasagittal Infarct on 2025-01-11)
Problem 4. Chronic Ischemic Heart Disease with Stable Angina
Problem 5. Type 2 Diabetes Mellitus (HbA1c 6.6 on 2025-02-03, Improved from 9.2 on 2024-12-06)
Summary of Key Actions
Since the last review on 2025-01-13, the patient has undergone significant clinical changes, including ischemic stroke, ongoing immunochemotherapy (FLOT + Nivolumab), and complications related to infections (urosepsis, vaginitis, and recurrent UTI). Problems identified are:
Additionally, the decision regarding the 2nd cycle of immunochemotherapy requires evaluation of the patient’s performance status (ECOG 1), infection control, hematologic reserves, and organ function stability.
Problem 1. Cerebrovascular Event (Acute Ischemic Stroke on 2025-01-15)
Problem 2. Hematologic and Renal Status (Anemia, Electrolyte Imbalance, Renal Function)
Problem 3. Infection Control (UTI, Vaginitis, and Sepsis)
Recommendation on 2nd Immunochemotherapy Session - Proceed with 2nd session of FLOT + Nivolumab, but with close monitoring.
[Patient Summary]
The patient, a 62-year-old female, presents with multiple complex medical issues, including:
The patient underwent neoadjuvant chemotherapy with the FLOT regimen (fluorouracil, leucovorin, oxaliplatin, and docetaxel) combined with nivolumab starting on 2025-01-01, alongside interventions to manage complications, including successful retrieval of a foreign body from the pulmonary artery (2024-12-31).
[Problem Comments]
Problem 1. Gastric Adenocarcinoma (Stage III, cT3N2M0)
Problem 2. Bloodstream Infection (Escherichia coli)
Problem 3. Anemia
Problem 4. Diabetes Mellitus
Problem 5. Cardiovascular Issues (Ischemic Heart Disease and Heart Failure)
[exam finding]
[MedRec]
2025-05-19 ~ 2025-05-23 POMR Hemato-Oncology Xia HeXiong
2025-02-04 ~ 2025-02-10 POMR Obstetrics and Gynecology Shao ZhiXuan
[surgical operation]
[radiotherapy]
[chemotherapy]
[exam finding]
[MedRec]
This is a 71-year-old male with pancreatic tail cancer with liver and gallbladder metastases, ECOG PS 2–3, who has opted for non-chemotherapeutic palliative care. Imaging on 2025-07-26 revealed a new nodular lesion in the left middle lung zone (r/o granuloma) and right-sided pleural effusion (CXR 2025-07-26). He presented with leukocytosis and CRP elevation, raising concern for infection vs tumor-related inflammation, and was started on Flumarin (flomoxef sodium) 1g q8h since 2025-07-26. Labs reveal anemia (Hb 9.5), neutrophilic leukocytosis (WBC 24.4, neutrophil 90.8%), hyponatremia (Na 126), and hypokalemia (K 3.3). He remains oriented, afebrile, and ambulatory via wheelchair, with ongoing supportive management and a family conference scheduled for 2025-07-30.
Problem 1. Advanced metastatic pancreatic cancer (with liver, gallbladder, and likely pulmonary metastasis)
Problem 2. Neutrophilic leukocytosis and systemic inflammation
Problem 3. Hyponatremia and hypokalemia
Problem 4. Normocytic anemia
[exam finding]
[MedRec]
A 92-year-old male with recently diagnosed ascending colon adenocarcinoma (biopsy 2025-06-25), presenting with extensive metastatic disease involving bilateral lungs, liver (S4/S8), peritoneum, bone (right iliac), pleural effusions positive for adenocarcinoma (cell block 2025-06-27, 2025-07-23), and malignant ascites (2025-07-03). Genomic profiling (2025-06-30) reveals TP53 R273C mutation, copy number amplifications (CCNE1, KAT6A), and deletions (PTEN, CHEK1, BRCA2, SMAD4) with microsatellite stable (MSS) and low TMB (1.9/Mb). Performance status is poor (ECOG 4, per 2025-06-16). Currently complicated by hyponatremia, volume overload, moderate anemia, and pleural and peritoneal effusions. No active systemic therapy has been initiated yet. Prognosis is poor.
Problem 1. Metastatic colon adenocarcinoma
Problem 2. Malignant pleural effusion and respiratory compromise
Problem 3. Malignant ascites and volume overload
Problem 4. Hyponatremia (Na 128 mmol/L on 2025-06-17)
Problem 5. Anemia and thrombocytosis
This is a 92-year-old female with metastatic colon cancer (lung metastases, malignant ascites), ECOG 4, referred from Cardinal Tien Hospital and not yet started on oncologic treatment. She presents with acute abdominal pain, vomiting, and functional decline. Significant comorbidities include heart failure, old cerebrovascular accident, diabetes, hypertension, and hypothyroidism. Clinical findings suggest possible concurrent infection (elevated CRP, leukocytosis, pyuria, bacteriuria, and positive urine yeast), ileus, and hypoalbuminemia. She is on empirical antibiotics and supportive care. Management complexity is high due to age, frailty, functional status, and multi-organ vulnerability.
Problem 1. Metastatic colorectal cancer with malignant ascites and ECOG 4
Problem 2. Possible urinary tract infection with fungal component
Problem 3. Ileus and gastrointestinal obstruction
Problem 4. Acute inflammation and systemic stress response
Problem 5. Hyponatremia and early renal impairment (not posted)
Problem 6. Polypharmacy and sedation risk (not posted)
[exam finding] (not completed)
2025-07-25 Sonography - nephrology
2025-07-24, 2025-07-09 CXR
2025-04-23 Wrist Rt
2025-04-10 KUB
2025-04-09 CXR
2025-04-09 CT
2025-04-09 Sonography - urology
2025-04-09 Sonography - nephrology
2025-03-19, 2025-02-19 Wrist Rt
2025-02-05 Merchant view (patella 45 0) Bilat
2025-01-25 L-spine flex. & ext. (including sacrum)
2025-01-14 Wrist Rt
2025-01-07 Hand Rt
2025-01-07 CT
2025-01-07 CT - brain
2025-01-07 Ribs Bilat
2025-01-07 Lower leg Lt
2024-12-18 CT - abdomen
2024-09-13 CT - abdomen
2024-06-12 CT - abdomen
2024-05-10 Bladder Sonography
2024-05-10 Uroflowmetry
2024-01-22 PET
2023-12-27 CT
2023-09-20 CT
2023-08-16 Pathology - prostate needle biopsy
2023-08-16 Pathology - prostate needle biopsy
2023-08-16 Transrectal Ultrasound of Prostate, TRUS-P
2023-08-07 CT
2023-07-12 Sonography - urology
2023-05-29 Tc-99m MDP bone scan
….-..-..
2023-03-15 PET
2023-03-09 CT - abdomen
2023-03-02 CT - abdomen
2022-10-13 CT - abdomen
2022-07-21 CT - abdomen
….-..-..
2021-03-31 Pathology - colon segmental resection for tumor
2021-03-31 Pathology - colon biopsy
[surgical operation]
[immunochemotherapy]
The patient has a history of distal descending colon adenocarcinoma (initially stage IIIC, now stage IV with lung metastasis) and high-risk prostatic adenocarcinoma. He presents with progressive lower back pain, elevated blood pressure, and impaired renal function with left hydronephrosis. Imaging and PET/bone scan are pending. Renal ultrasound confirms chronic renal parenchymal disease and left-sided hydronephrosis (ultrasound 2025-07-25). Labs show borderline anemia (HGB 10.5 g/dL), impaired renal function (eGFR 30.4), and hypertension. He was admitted for staging evaluation and chemotherapy planning.
Problem 1. Progressive colon cancer with systemic metastasis
Problem 2. Suspected bone metastasis and lower back pain
Problem 3. Chronic renal dysfunction with left hydronephrosis (not posted)
Problem 4. Prostatic adenocarcinoma, high-risk, now in remission
Problem 5. Anemia (borderline) and fatigue (not posted)
[MedRec]
The patient is a nonagenarian male with multiple chronic illnesses including prostate cancer (well-controlled under ADT), chronic Foley use with recurrent catheter-associated urinary tract infections (CAUTIs), advanced dementia with neuropsychiatric symptoms, type 2 diabetes, CAD, dyslipidemia, and a history of colon cancer. He is bedridden, functionally dependent, and under regular home-based care (HaH). He recently completed IV antibiotics (ceftriaxone) for multidrug-resistant urinary pathogens with apparent resolution. His renal and hepatic functions are preserved, glycemic and lipid control are acceptable, and current medications address neuropsychiatric symptoms, cardiovascular protection, and supportive care. Preventive strategies for pressure injuries, infection, and aspiration are in place.
Problem 1. Recurrent catheter-associated urinary tract infections (CAUTIs)
Problem 2. Prostate cancer under hormonal therapy
Problem 3. Dementia with behavioral and neuropsychiatric symptoms
Problem 4. Type 2 diabetes mellitus
Problem 5. Cardiovascular disease and dyslipidemia
Problem 6. Functional dependence and frailty
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
The patient is a male with metastatic castration-resistant prostate cancer (mCRPC), showing disease progression despite prior hormonal therapy. PSA remains markedly elevated (543.172 on 2025-04-23 → 451.931 on 2025-04-30 → 27.830 on 2025-06-12), likely in response to newly initiated therapy. He also presents with chronic kidney disease stage 4 (eGFR 22-30), anemia, hyperlipidemia, and borderline hypotension. Active treatment includes Nubeqa (darolutamide), Harnalidge (tamsulosin), and Crestor (rosuvastatin). He recently completed a short course of Ulstop (famotidine) and had one-time dosing of Limeson (dexamethasone).
Treatment timeline:
Problem 1. Advanced prostate cancer with metastatic disease
Problem 2. Chronic kidney disease, stage 4
Problem 3. Anemia, normocytic
Problem 4. Hyperlipidemia
Problem 5. Hypotension and bradycardia episodes (not posted)
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
The patient, with metastatic pancreatic neuroendocrine tumor (PanNET) post distal pancreatectomy and splenectomy, is currently undergoing platinum-based chemotherapy (etoposide + carboplatin), with the 12th cycle started on 2025-07-23 (the first cycle using cisplatin). Imaging (CT 2025-06-26) indicates progression of liver metastases and lymphadenopathy despite stable tumor markers (CEA, AFP, CA199), suggesting partial radiologic progression. The patient maintains stable renal and hepatic function and has tolerated chemotherapy well hematologically. Post-ORIF recovery for right distal radius fracture is uneventful. Anemia is stable, normocytic, likely related to chronic disease and chemotherapy. Vital signs remain hemodynamically stable. Attention is warranted for evolving nutritional risk (low uric acid, borderline albumin), and surveillance imaging is recommended.
Problem 1. Metastatic pancreatic neuroendocrine tumor (PanNET), with progressive liver and nodal metastases
Problem 2. Anemia, normocytic, chemotherapy-associated (not posted)
Problem 3. Chronic kidney disease, stable, chemotherapy-exacerbated (not posted)
Objective
Assessment
Recommendation
Problem 4. Right distal radius fracture, s/p ORIF (not posted)
Problem 5. Nutritional/metabolic risk with falling uric acid (not posted)
Summary
Problem 1: Neuroendocrine Carcinoma – Systemic Treatment Response
Problem 2: Renal Function Decline
Problem 3: Metabolic Changes – Low Uric Acid and LDH (below not posted)
Conclusion:
[Patient Summary]
This is a 63-year-old male with a complex medical history, primarily notable for pancreatic neuroendocrine tumor (PNET) with liver metastases, recurrent metastatic disease, and secondary primary lung adenocarcinoma. He has undergone extensive surgical interventions, radiofrequency ablation (RFA), and systemic chemotherapy over the years. Disease progression includes liver metastases, mediastinal lymph node involvement, and systemic complications like hoarseness due to vocal cord paralysis. He has a history of chronic hepatitis B and hypertension, and his treatments have included targeted therapies (e.g., sunitinib) and systemic chemotherapy. Current ongoing treatment involves etoposide-carboplatin for metastatic neuroendocrine tumor.
Key areas of concern include the ongoing metastatic burden in the liver and lymph nodes, hoarseness (2024-10-30 thyroplasty), and maintaining the balance between disease control and side effect management.
[Problem Comments]
Problem 1. Metastatic Neuroendocrine Tumor (Liver and Lymph Nodes)
Problem 2. Secondary Primary Lung Adenocarcinoma
Problem 3. Hepatitis B, Liver and Kidney Funtion
[MedRec]
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
[Subjective]
dual antiplatelet therapy adherence and blood pressure monitoring
[Objective]
current medications (prescribed on 2025-07-18)
vital signs
labs and diagnostics
[Assessment]
dual antiplatelet therapy post-PCI
[Plan / Recommendation]
optimize medication safety and adherence
This is a 45-year-old woman with a recent ST-elevation myocardial infarction (STEMI, Killip III) on 2025-04-18, successfully managed with percutaneous coronary intervention (PCI) to the LAD using a drug-eluting stent. Comorbidities include heart failure with reduced ejection fraction (HFrEF, LVEF 31–39%), type 2 diabetes mellitus with poor glycemic control (HbA1c 10.0%), asthma, mixed hyperlipidemia, and polycystic kidney disease with mildly reduced eGFR (~59). She remains NYHA II and hemodynamically stable. Discharge medications include dual antiplatelet therapy, comprehensive heart failure regimen (including Entresto), and a multi-agent antihypertensive and antidiabetic plan. Post-infarction rehabilitation has begun. Renal function, cardiac enzymes, and inflammatory markers are stable, and blood counts normalized after acute stress.
Problem 1. Ischemic heart disease (STEMI, post-PCI LAD)
Problem 2. Heart failure with reduced ejection fraction (HFrEF)
Problem 3. Poorly controlled diabetes mellitus (HbA1c 10.0%)
Problem 4. Chronic kidney disease, polycystic type
Problem 5. Mixed hyperlipidemia
Problem 6. Asthma (stable)
[exam finding]
[MedRec]
[Subjective]
Fruzaqla therapy status
Medication understanding
[Objective]
Medication and monitoring status
[Assessment]
Fruzaqla tolerability
Supportive care and counseling
[Plan / Recommendation]
Continue Fruzaqla therapy
Monitoring plan
Supportive care and education
This is a 59-year-old man with rectal adenocarcinoma (cT2N1aM1a, stage IVA), status post CCRT and robotic LAR with ileostomy on 2023-12-20, with persistent liver and lung metastases despite multiple lines of systemic therapy. He progressed under Avastin + FOLFOXIRI, then Lonsurf and Stivarga. A recent workup confirmed NRAS mutation, HER2 negative, and microsatellite stability. PET (2025-06-19) confirmed extensive FDG-avid metastatic disease. Liver biopsy (2025-06-17) reconfirmed metastatic colorectal adenocarcinoma. After discussion, he was started on oral Fruzaqla (fruquintinib) from 2025-07-14. Despite disease progression, his performance status remains ECOG 1, with preserved organ function.
Problem 1. Progressive metastatic rectal adenocarcinoma (stage IVA, NRAS-mutated, HER2-negative, MSS)
Problem 2. Anemia and thrombocytopenia (likely chemotherapy-related, normocytic)
Problem 3. Liver function and hepatotoxicity monitoring
Problem 4. Cardiopulmonary status prior to and during anti-VEGFR therapy
Problem 5. Chronic hepatitis B (resolved infection, anti-HBc+)
[MedRec]
2025-06-22 ~ XXXX-XX-XX POMR Hemato-Oncology Xia HeXiong
2025-04-16 SOAP Cardiology Ye GuanHong
2025-04-16 SOAP Neurology Yang FuYi
[MedRec]
[exam finding]
[MedRec]
2025-07-11 ~ XXXX-XX-XX POMR Hemato-Oncology Lin YiTing
2025-04-13 ~ 2025-04-28 POMR Urology You ZhiQin
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[note]
Non-Hodgkin lymphoma ESHAP (etoposide methylprednisolone cytarabine ciSplatin) - 20250623 - https://www.eviq.org.au/haematology-and-bmt/lymphoma/other-b-cell-lymphoma/124-eshap-etoposide-methylprednisolone-cytarabine
Chemotherapy regimen: ESHAP - 20250623 - https://hivclinic.ca/main/drugs_chemo_files/ESHAP.pdf
This is a 78-year-old male with relapsed classical Hodgkin lymphoma (Lugano stage ≥III, CD15+, CD30+, B2-microglobulin 3916, ESR 80) undergoing the 4th cycle (C4) of ESHAP chemotherapy since 2025-07-15. The patient also has rheumatoid arthritis, polymyositis (prior rituximab therapy 2017–2019), antiphospholipid syndrome with prior DVT, and prior history of colon cancer (stage I), all contributing to a complex comorbidity profile. He has tolerated C1–C3 ESHAP cycles well, with regression of axillary disease noted. Current admission is stable, with no major symptoms, hemodynamic instability, or laboratory evidence of acute organ toxicity. Supportive medications and vital signs are well maintained.
Problem 1. Relapsed classical Hodgkin lymphoma, Lugano stage ≥III
Problem 2. Bone marrow suppression under ESHAP chemotherapy
Problem 3. Renal and hepatic function under chemotherapy (not posted)
Problem 4. Cardiovascular risk and blood pressure control
Problem 5. Comorbid autoimmune disease (RA, polymyositis)
This 78-year-old man has a complex medical history including:
Problem 1. Relapsed Classical Hodgkin Lymphoma
Problem 2. Cytopenia – Anemia and Myeloproliferation
Problem 3. Cardiopulmonary Function and Comorbid COPD (not posted)
Problem 4. Cardiovascular and Thromboembolic Risks
Problem 5. Dermatologic Issue – Scalp Eczema (not posted)
[MedRec]
[exam finding]
[exam finding]
[MedRec]
[Subjective]
medication understanding and adherence
lipid management discussion
follow-up planning
[Objective]
medication regimen
lab results (2025-07-04)
clinical status
[Assessment]
antiplatelet therapy adherence
lipid optimization
residual coronary disease planning
[Plan / Recommendation]
support and reinforce DAPT adherence
optimize lipid profile
cardiology coordination
pharmacovigilance
[Subjective]
medication counseling
lifestyle and history
[Objective]
lab data on 2025-06-02
cardiology record
[Assessment]
dual antiplatelet therapy adherence importance
hyperuricemia management
[Plan / Recommendation]
reinforce antiplatelet adherence
gout management strategy
optimize lipid management
lifestyle and long-term care
Key Insights / Summary
Problem 1. Coronary artery disease post-NSTEMI with incomplete revascularization
Problem 2. Lipid control for secondary prevention
Problem 3. Dual antiplatelet therapy adherence and bleeding risk
Problem 4. Hyperuricemia with history of gout
Problem 5. Mildly reduced LV systolic function (HFmrEF)
[exam finding]
[MedRec]
[consultation]
2025-04-02 Rehabilitation
2025-03-28 Cardiology
2024-02-05 Urology
[chemotherapy]
2024-09-18 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-08-07 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-07-09 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-06-11 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-05-07 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
2024-04-17 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
2024-03-27 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
2024-02-27 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2023-12-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-12-07 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr
2023-11-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-10-18 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-10-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-09-26 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-09-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-09-05 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-08-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-08-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr
2023-08-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-07-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-06-27 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-06-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-06-06 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-05-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-05-16 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
……….
2020-12-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-12-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-12-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-11-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr
2020-10-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr
2020-10-07 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr
2020-09-18 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr + temozolomide 140mg PO D1-2
[Subjective]
anticoagulation therapy and adherence
cardiovascular medication use and tolerance
cancer-related symptoms and general status
[Objective]
vital signs and recent clinical data
medication list
Pentop (pentoxifylline 400mg) 1# QD
Crestor (rosuvastatin 10 mg) 1# QD
Forxiga (dapagliflozin 10 mg) 1# QDAC
Concor (bisoprolol 1.25 mg) 1# QD
Lixiana (edoxaban 30 mg) 1# QD
Ulstop (famotidine 20 mg) 1# QD
medications discontinued: Entresto (sacubitril/valsartan), Aldactone (spironolactone), and Plavix (clopidogrel) (per 2025-07-10 cardiology note)
[Assessment]
anticoagulation therapy
cardiac medication adjustments
oncologic symptom control
[Plan / Recommendation]
anticoagulation therapy
cardiovascular medication management
oncology and supportive care
renal monitoring
medication reconciliation and education
[Subjective]
cardiovascular status post PCI
oncology background
[Objective]
vital signs and physical findings
recent labs (selected)
medication profile (2025-04-17 prescription)
[Assessment]
antithrombotic therapy
heart failure management
diabetes/diuretic agent
dyslipidemia
GI protection
oncologic considerations
[Plan / Recommendation]
antithrombotic strategy
heart failure and cardiac medications
diabetes/diuretic agent
dyslipidemia
GI protection
oncology follow-up
adherence and education
Key Insights / Summary
Problem 1. Advanced metastatic endometrial stromal sarcoma
Problem 2. Myelosuppression under liposomal doxorubicin therapy
Problem 3. Progressive chronic kidney disease
Problem 4. Pleural effusion and pulmonary involvement
Problem 5. History of brain metastasis and post-craniotomy status
[exam finding]
[chemotherapy]
[MedRec]
[exam finding]
[MedRec]
[radiotherapy]
[immunochemotherapy]
Key Insight / Summary
Problem 1. Stage IVC supraglottic squamous cell carcinoma with lung metastases
Problem 2. Chemotherapy-induced myelosuppression
Problem 3. Renal function under cisplatin-based chemotherapy
Problem 4. Treatment-related anemia and thrombocytopenia
Problem 5. Systemic inflammation and liver function
Problem 6. Cardiovascular comorbidity - Hypertension
Problem 7. Nutritional and metabolic status
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
2025-01-16 ~ 2025-03-18 - 4500cGy/25 fractions of the pelvic to paraaortic area, 5040cGy/28 fractions of the cervical tumor, and 7020cGy/39 fractions of the cervicla tumor bed.
[chemotherapy]
This is a 68-year-old woman with stage IVB poorly differentiated adenocarcinoma of the uterine cervix (cT3bN2M1), with metastases to lung, mediastinal and paraaortic lymph nodes, and bone. She is under combination therapy with pembrolizumab, bevacizumab, and paclitaxel. Carboplatin was omitted from the C6 regimen on 2025-08-28 due to worsening renal function (Cr 3.15 mg/dL, eGFR 15.64 mL/min/1.73m² on 2025-08-27). She also has persistent normocytic anemia, thrombocytopenia, hypocalcemia, hypomagnesemia, and chronic hepatitis B. PET on 2025-07-16 shows no definite metastasis, suggesting a possible partial response. Her general condition is stable with ECOG PS 2, no dyspnea, no mucositis, and adequate peripheral perfusion.
(below not posted)
Problem 1. Progressive Renal Dysfunction (CKD stage IV)
Problem 2. Myelosuppression with Normocytic Anemia and Thrombocytopenia
Problem 3. Hypocalcemia and Hypomagnesemia
Problem 4. Cervical Cancer with Partial Response Post C5-C6 Therapy
Problem 5. Chronic Hepatitis B (HBV carrier) (not posted)
Problem 1. Chronic kidney disease, stage IV with metabolic acidosis
Problem 2. Poorly differentiated adenocarcinoma of the uterine cervix, stage IV (cT3bN2M1)
Problem 3. Anemia and thrombocytopenia under chemotherapy (not posted)
Problem 4. Hypocalcemia and hypomagnesemia
Problem 5. Hypertension
[Treatment Suggestions Based on Guidelines and Current Patient Status] (not posted)
This is a 68-year-old woman with FIGO stage IVB poorly differentiated adenocarcinoma of the uterine cervix, currently receiving immunotherapy and chemotherapy. Given her updated status — including impaired renal function (eGFR 15.6 mL/min/1.73m²), ECOG PS 2, anemia, thrombocytopenia, and imaging showing no definite metastasis — treatment strategy should balance efficacy, organ function safety, and tolerability.
Most Preferred to Least Preferred Options:
Additional Notes:
Conclusion:
Problem 1. Metastatic Cervical Cancer (T3bN2M1)
Problem 2. Hematological Abnormalities: Anemia and Thrombocytopenia
Problem 3. Renal Dysfunction
Problem 4. Electrolyte Imbalance and QT Prolongation Risk
Problem 5. Infection and Inflammation Surveillance
Problem 6. Cardiovascular Monitoring (not posted)
Problem 7. Endocrine and Nutritional Status
This is a 67-year-old woman with poorly differentiated adenocarcinoma of the uterine cervix, stage T3bN2M1 (AJCC 9th edition) (MRI 2025-01-06, pathology 2025-01-07), presenting with lung, bone, and nodal metastases (CT 2025-01-09, MRI 2025-01-06). She has received concurrent chemoradiotherapy (CCRT) and is undergoing palliative chemotherapy with carboplatin ± bevacizumab. She has chronic HBV infection (Anti-HBc reactive, HBsAg non-reactive, 2025-02-07) and a history of liver cirrhosis. Her clinical course is complicated by chronic anemia, thrombocytopenia, progressive CKD, mild electrolyte disturbances (hypocalcemia, hypomagnesemia), and systemic inflammation with intermittent elevation of CRP. ECG on 2025-03-21 revealed prolonged QT, necessitating close electrolyte and ECG monitoring. Despite metastatic disease, vital signs remain stable (as of 2025-03-24), and no recent infection signs were evident (PCT 0.16 ng/mL on 2025-03-24).
Problem 1. Metastatic Cervical Cancer (T3bN2M1)
Problem 2. Chronic Anemia
Problem 3. Thrombocytopenia
Problem 4. Progressive Chronic Kidney Disease (CKD)
Problem 5. Electrolyte Imbalance and QT Prolongation
Problem 6. Chronic HBV Infection with Cirrhosis
Problem 7. Inflammatory Activity and Infection Surveillance
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[cetuximab - infusion reaction and respiratory adverse events]
Here are several academic articles and authoritative resources that address infusion reactions and respiratory adverse events—such as cough, dyspnea, and pharyngitis—associated with cetuximab:
Infusion Reactions
Respiratory Adverse Reactions
Useful Articles and Resources
| Citation | Key Focus |
|---|---|
| 1 | Incidence and risk factors for infusion reactions in HNSCC |
| 2 | Timing and severity of IRs in colorectal cancer |
| 10 | Meta-analysis of pulmonary/respiratory adverse reactions |
| 7 | Product monograph with IR and anaphylaxis details |
| 4 | Review of IR pathology and management |
| 5 | StatPearls clinical review with adverse event percentages |
| 9 | Comprehensive list of respiratory and other side effects |
| 11 | Case report of severe pulmonary adverse events |
These articles and reviews provide detailed information on the frequency, management, and risk factors for infusion and respiratory adverse reactions with cetuximab, along with data for specific symptoms (dyspnea, cough, pharyngitis). They will serve as strong starting points for any academic literature review or in-depth analysis on the topic.
1 https://pmc.ncbi.nlm.nih.gov/articles/PMC6069910/ 2 https://pmc.ncbi.nlm.nih.gov/articles/PMC4033604/ 3 https://www.spandidos-publications.com/10.3892/mco.2017.1242 4 https://www.cancernetwork.com/view/cetuximab-associated-infusion-reactions-pathology-and-management 5 https://www.ncbi.nlm.nih.gov/books/NBK459293/ 6 https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/125084lbl.pdf 7 https://pi.lilly.com/ca/erbitux-ca-pm.pdf 8 https://bmccancer.biomedcentral.com/articles/10.1186/s12885-022-10192-4 9 https://www.drugs.com/sfx/cetuximab-side-effects.html 10 https://pmc.ncbi.nlm.nih.gov/articles/PMC2735734/ 11 https://www.zora.uzh.ch/id/eprint/64181/1/Zaugg_K._A_rare_but_severe_BMJ_Case_Rep._12.pdf 12 https://www.spandidos-publications.com/10.3892/mco.2017.1242/abstract 13 https://pmc.ncbi.nlm.nih.gov/articles/PMC3937754/ 14 https://cjcr.amegroups.org/article/view/3356/4189 15 https://www.sciencedirect.com/science/article/pii/S0923753419394694 16 https://www.sciencedirect.com/science/article/pii/S0954611111003969 17 https://ascopubs.org/doi/10.1200/jco.2011.29.15_suppl.e14075 18 https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/125084s273lbl.pdf 19 https://erbitux.lilly.com/hcp/locally-advanced-scchn 20 https://www.accessdata.fda.gov/drugsatfda_docs/nda/2021/125084Orig1s277,s280.pdf
This is an 80-year-old male with p16-positive poorly differentiated squamous cell carcinoma (SCC) of the right oropharynx (cT4N2M0, stage III), undergoing bio-radiotherapy with cetuximab since 2025-06-25. The patient developed febrile illness with elevated inflammatory markers on 2025-07-12, suspected sepsis with likely urinary source, and clinical oral candidiasis. Concurrently, there is progressive oropharyngeal tumor with airway obstruction (nasopharyngoscopy 2025-06-25). He has multiple comorbidities including type 2 diabetes mellitus (HbA1c 8.4% on 2025-05-12), hypertension, esophageal dysplasia, and renal atherosclerosis. Recent labs show worsening thrombocytopenia, mild hyponatremia, and hs-Troponin I elevation without chest symptoms.
Problem 1. Sepsis with possible urinary tract infection
Problem 2. Mucositis with suspected oral candidiasis
Problem 3. Progressive oropharyngeal carcinoma (cT4N2M0, p16+)
Problem 4. Thrombocytopenia and anemia during therapy
Problem 5. Hyperglycemia in T2DM under stress
Problem 6. hs-Troponin I elevation without chest symptoms
Problem 7. Chronic esophageal lesion with dysplasia
[exam finding]
[MedRec]
2025-05-23 ~ 2025-05-31 POMR Hemato-Oncology Xia HeXiong
2025-04-19 ~ 2025-04-25 POMR Chest Medicine Huang GuoLiang
2025-02-26 ~ 2025-03-03 POMR Ear Nose Throat Huang TongCun
2025-02-11 ~ 2025-02-20 POMR Ear Nose Throat Huang TongCun
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This 71-year-old male with a complex oncologic history—recurrent right oropharyngeal squamous cell carcinoma (initially cT4aN2bM0, stage IV) status post multiple surgeries and CCRT (2023-07 to 2023-09)—is currently undergoing PF4 chemotherapy (cisplatin + fluorouracil) initiated on 2025-05-26 due to recurrent disease identified on PET (2025-05-12) and MRI (2025-05-07). He recently completed his third PF4 cycle (2025-07-11 to 2025-07-14) and is experiencing chemotherapy-induced diarrhea without significant systemic compromise. His renal, liver, and hematological functions remain preserved. Glycemic control is suboptimal under current oral hypoglycemics.
Problem 1. Recurrent oropharyngeal squamous cell carcinoma (cT4aN2bM0)
Problem 2. Glycemic fluctuation under type 2 diabetes treatment
Problem 3. Diarrhea during chemotherapy
Problem 4. Hematologic status
Problem 5. Renal and hepatic function (not posted)
[Recommendation for Concor (Bisoprolol 1.25mg/tab) Tube Feeding]
Concor (bisoprolol) IR tablets are suitable for administration via a feeding tube using the following steps:
Preparation (Simple Suspension Method)
Administration Procedure
Additional Considerations
This is a 71-year-old male with an oncologic history of recurrent SCC involving the right oropharynx, tongue, and palate (initial stage cT4aN2bM0, post multiple surgeries and CCRT). Despite extensive treatments including tongue/palate resections, neck dissections, free flap and STSG reconstructions, and CCRT (2023-07 to 2023-09), recent PET (2025-05-12) and MRI (2025-05-07) suggest multifocal local recurrence involving the right oropharyngeal wall, tongue, and mouth floor. He is undergoing neoadjuvant chemotherapy with PF4 regimen (cisplatin + 5-FU), started 2025-05-26 and again administered on 2025-06-20. Comorbidities include CAD post-CABG (2023-02), type 2 diabetes, hypertension, dyslipidemia, GERD, and chronic otitis media. Current clinical status is stable (ECOG 2), vital signs are acceptable, and labs show normal hepatic and renal function, but intermittent hyperglycemia is noted.
Problem 1. Recurrent right oropharyngeal and oral SCC, post CCRT and multiple resections
Problem 2. Glycemic instability in type 2 diabetes mellitus
Problem 3. Cardiovascular disease post-CABG
Problem 4. Hematological tolerance during chemotherapy (not posted)
Problem 5. Gastrointestinal symptoms and mucosal protection (not posted)
This 71-year-old male with a complex history of recurrent, multifocal squamous cell carcinoma (SCC) of the oropharynx and oral cavity (right tongue, floor of mouth, and palate) has undergone multiple surgeries including wide excisions, STSG, free flap reconstruction, and radiotherapy. Imaging (PET 2025-05-12, MRI 2025-05-07) confirms new recurrent disease in the oropharynx and oral cavity. As of 2025-05-26, he remains in stable condition, planned for further chemotherapy. Renal function is preserved (CCr 82.3 mL/min on 2025-05-24), and hematologic parameters show no major cytopenias despite chronic inflammation (CRP peaked at 8.4 mg/dL on 2025-04-18, now downtrending). Blood glucose is moderately elevated with known type 2 DM, previously managed with Tresiba (insulin degludec) and oral agents.
Problem 1. Locoregionally Recurrent Multifocal Oral and Oropharyngeal Squamous Cell Carcinoma
Problem 2. Renal Function and Chemotherapy Clearance (not posted)
Problem 3. Hematologic and Inflammatory Status (not posted)
Problem 4. Type 2 Diabetes and Glycemic Control
Problem 5. Cardiovascular Comorbidities and Onco-cardiology Risk
[lab data]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[note]
Comprehensive Evidence-Based Protocol for Platinum Agents and Hemodialysis - 20250619 - perplexity.ai
Cisplatin Administration
Carboplatin Administration
Oxaliplatin Administration
Integrated Comparison of Protocols
| Parameter | Cisplatin | Carboplatin | Oxaliplatin |
|---|---|---|---|
| HD Timing | ≤3h post-infusion | 16-20h post-infusion | 1-2h post-infusion |
| Dose Reduction | 50-75% | AUC×25 (GFR=0) | 50% |
| Dialyzability | Low (unbound fraction) | High (>50%) | Moderate (50-80%) |
| Key Evidence | 34 | 56 | 32 |
Critical Implementation Principles
Evidence Hierarchy
1 https://www.sciencedirect.com/science/article/pii/S0923753419394888 2 https://pmc.ncbi.nlm.nih.gov/articles/PMC5703391/ 3 https://clinmedjournals.org/articles/ijor/international-journal-of-oncology-research-ijor-2-017.php 4 https://www.spandidos-publications.com/10.3892/br.2016.714/download 5 https://pmc.ncbi.nlm.nih.gov/articles/PMC10337679/ 6 https://pmc.ncbi.nlm.nih.gov/articles/PMC4321781/ 7 https://www.stonybrookmedicine.edu/sites/default/files/renal-impairment-dosage-adjustment-for-cytotoxics.pdf 8 https://pmc.ncbi.nlm.nih.gov/articles/PMC5844381/ 9 https://pmc.ncbi.nlm.nih.gov/articles/PMC8753493/ 10 https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2019.01485/pdf 11 https://www.neuroquantology.com/open-access/Comparative+Evaluation+of+Renal+Parameters+in+Patients+Treated+with+Cisplatin%252C+Carboplatin%252C+and+Oxaliplatin_14673/?download=true 12 https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Uterine-cancer/Endometrial-Carboplatin-Cisplatin-Paclitaxel-RT-21day.pdf 13 https://pcm.amegroups.org/article/view/8174/html 14 https://journals.lww.com/anti-cancerdrugs/Fulltext/2015/08000/Administration_of_chemotherapy_in_patients_on.11.aspx?generateEpub=Article%7Canti-cancerdrugs%3A2015%3A08000%3A00011%7C10.1097%2Fcad.0000000000000243%7C 15 https://www.mdpi.com/1422-0067/21/18/6928 16 https://www.clinicalkey.com
Enhanced Evidence-Based Summary: Timing of Platinum-Based Chemotherapy and Hemodialysis - 20250619 - chatgpt.com
Cisplatin
Carboplatin
Oxaliplatin
Summary Comparison
| Agent | HD Timing | Dose Adjustment | Evidence Level |
|---|---|---|---|
| Cisplatin | ≤3 hr post-infusion | 25–50% standard dose | Moderate: PK studies, clinical cases 6 |
| Carboplatin | 12–20 hr post-infusion | Calvert (AUC×25 mg) | Strong: PK studies, AUC targets |
| Oxaliplatin | 1–2 hr post-infusion | 50% dose | Emerging: Limited case reports |
Key Clinical Guidelines
Administering hemodialysis (HD) immediately after cisplatin (CDDP) infusion - 20250619 - plerplexicy.ai
Administering hemodialysis (HD) immediately after cisplatin (CDDP) infusion does not necessarily reduce its effectiveness when accompanied by appropriate dosing adjustments and timing protocols. Below is an evidence-based analysis:
Key Pharmacokinetic Mechanism
Clinical Evidence from Studies
Balancing Efficacy and Safety
| Factor | Impact on Efficacy | Clinical Recommendation |
|---|---|---|
| HD Timing | Early HD reduces free cisplatin but spares bound drug | Initiate HD ≤3h post-infusion |
| Dose Adjustment | Lower doses (25–50% reduction) maintain efficacy | Use 25–50 mg/m² for safety |
| Protein Binding | Bound fraction remains active post-HD | No efficacy loss if binding occurs |
Conclusion
Immediate HD after cisplatin administration does not diminish effectiveness when:
1 https://pubmed.ncbi.nlm.nih.gov/18191389/ 2 https://www.dovepress.com/systemic-treatment-for-gynecological-cancer-patients-undergoing-hemodi-peer-reviewed-fulltext-article-OTT 3 https://pmc.ncbi.nlm.nih.gov/articles/PMC6505661/ 4 https://www.nature.com/articles/6600687 5 https://ecancer.org/es/journal/article/1397-successful-treatment-of-a-patient-with-renal-failure-treated-with-haemodialysis-and-advanced-ovarian-germ-cell-tumour-using-modified-cisplatin-based-chemotherapy-duplet/pdf 6 https://pmc.ncbi.nlm.nih.gov/articles/PMC2376779/ 7 https://journals.lww.com/anti-cancerdrugs/Fulltext/2020/10000/Full_dose_cisplatin_chemotherapy_combined_with.14.aspx?generateEpub=Article%7Canti-cancerdrugs%3A2020%3A10000%3A00014%7C10.1097%2Fcad.0000000000000911%7C 8 https://www.sciencedirect.com/science/article/pii/S0923753419394888 9 https://www.ncbi.nlm.nih.gov/books/NBK547695/ 10 https://www.frontiersin.org/journals/nephrology/articles/10.3389/fneph.2024.1436896/full
Does HD immediately after cisplatin reduce its effectiveness? - 2025-06-19 - chatgpt.com
| Timing & Dose | Free Platinum Removed | Efficacy Impact | Notes |
|---|---|---|---|
| HD ≤3 h post-infusion | Yes (unbound only) | No significant reduction | Maintains protein-bound active drug |
| Reduced dose (25–50%) | Yes | Effective in small studies | Supports tolerability without compromise |
This is a 48-year-old man with esophageal squamous cell carcinoma (cT3N2M0, stage IIIB) status post CCRT (2022-11-02 to 2023-02-09) and esophagectomy with gastric tube reconstruction (2023-03-27), now with progressive metastatic disease to liver, kidneys, and retroperitoneal lymph nodes. He has received third-line chemotherapy with paclitaxel + carboplatin since 2025-04-17. He was hospitalized from 2025-05-28 to 2025-07-05 primarily for chemotherapy (3rd cycle) and symptom control. During admission, he developed healthcare-associated pneumonia (RUL consolidation and crackles) and tested positive for COVID-19 (2025-07-01), though symptoms were mild. Comorbidities include chronic kidney disease (stage 5), cachexia (BMI 12.9), anemia, and opioid-induced constipation. Discharged in stable condition with oral medications including magnesium oxide, sennoside, dulcolax, Nexium, and morphine.
Problem 1. Progressive metastatic esophageal squamous cell carcinoma
Problem 2. Healthcare-associated pneumonia with concurrent COVID-19 positivity (not posted)
Problem 3. Chronic kidney disease, stage 5 (not posted)
Problem 4. Anemia and thrombocytopenia under chemotherapy
Problem 5. Opioid-induced constipation
Problem 6. Cachexia
This is a 48-year-old male with esophageal squamous cell carcinoma (M/3, initially cT3N2M0 stage IIIB), who underwent definitive concurrent chemoradiotherapy (PF regimen) starting on 2022-11-02 followed by three-dimensional video-assisted thoracoscopic esophagectomy and gastric tube reconstruction on 2023-03-27. Despite initial surgical remission (ypT3N1M0), disease progression with bilateral renal and hepatic metastases has occurred. Biopsies on 2024-08-20 and 2024-08-21 confirmed metastatic squamous cell carcinoma in both kidneys. Recent imaging (CT 2025-04-01, CXR 2025-05-28) shows stable hepatic/renal tumors and new consolidation over the right upper lung compatible with pneumonia.
Problem 1. Pneumonia with new right upper lobe consolidation
Problem 2. Metastatic esophageal squamous cell carcinoma with bilateral renal and hepatic metastases
Problem 3. Anemia in setting of malignancy and ESRD
Problem 4. Electrolyte and renal disturbances in ESRD with tumor involvement
[nivolumab added to triplet chemotherapy with upward SCC trend]
PD-L1 tumor cell (TC) staining shows 7% expression (between 5% and 10%). Nivolumab was initiated on 2024-10-01 in combination with triplet chemotherapy (docetaxel, cisplatin, fluorouracil).
The tumor marker SCC has been trending upward steadily since 2023Q3. As nivolumab has just been added, continued follow-up is recommended to monitor treatment efficacy. No medication issues have been identified.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[note]
Non-Hodgkin lymphoma ESHAP (etoposide methylprednisolone cytarabine cisplatin) - 2025-06-02 - https://www.eviq.org.au/haematology-and-bmt/lymphoma/other-b-cell-lymphoma/124-eshap-etoposide-methylprednisolone-cytarabine
Initial treatment of peripheral T cell lymphoma - INDUCTION THERAPY - 2023-11-24 - https://www.uptodate.com/contents/initial-treatment-of-peripheral-t-cell-lymphoma
As of 2025-07-03 (Day +21 post-haploidentical allo-PBSCT), the patient shows stable clinical status with no signs of active GVHD or infection. Neutrophil engraftment has occurred (WBC 8.71 ×10³/uL on 2025-07-02), and oral intake is improving. Diarrhea has resolved; only mild abdominal discomfort remains. Immunosuppression continues with IV ciclosporin and oral mycophenolate mofetil. Letermovir and valacyclovir are used for CMV/HSV prophylaxis. Zinc level is within upper-normal limits (1011 µg/L on 2025-07-02). Nutritional status is monitored, with gradual tapering off of TPN considered.
Problem 1. Post-allo PBSCT Immune Reconstitution
Problem 2. Gastrointestinal Symptoms (Mild Abd Pain and Previous Diarrhea) (not posted)
Problem 3. Anemia and Thrombocytopenia
Problem 4. Infection Prophylaxis and Viral Reactivation
This 25-year-old male is on Day +15 post-haploidentical allo-PBSCT for recurrent CD30-negative peripheral T-cell lymphoma. As of 2025-06-27, he demonstrates evidence of neutrophil engraftment (WBC 4.65 x10^3/uL, Neutrophils 85.0%) and improving mucositis (Grade 1), without ongoing fever or respiratory distress. Ongoing challenges include thrombocytopenia (PLT 56 x10^3/uL), persistent anemia (HGB 9.0 g/dL), immunosuppression monitoring, and TPN support due to prior poor oral intake. CMV is being prophylactically managed with Brand Name (letermovir), and active infection appears absent.
Problem 1. Post-allo-PBSCT Immunologic Recovery
Problem 2. Nutritional Support and TPN Management
Problem 3. Electrolyte Imbalances (Mg, Ca, P) (not posted)
Problem 4. Immunosuppression and GVHD Prophylaxis
Problem 5. Infection Prophylaxis and Surveillance (Including CMV)
Key Insight / Summary
Problem 1. Profound Neutropenia with Sepsis Risk
Problem 2. Persistent Thrombocytopenia and Anemia
Problem 3. Gastrointestinal Mucositis and Diarrhea
Problem 4. Nutritional Support and Weight Loss
Problem 5. Immunosuppression Post-allo PBSCT
Problem 6. CMV Prophylaxis Post-Allo PBSCT
[Recommendation with Critical Considerations for Prevymis (letermovir) tube-feeding]
If absolutely no alternatives exist (oral pellets or IV formulation unavailable), SSM may be considered as a last resort, but with these conditions:
Step-by-Step SSM Protocol (Based on Limited Evidence). If proceeding despite risks:
Critical Precautions:
Risks vs. Alternatives
| Factor | SSM with Tablets | Official Alternatives |
|---|---|---|
| Approval | Not approved14 | Pellets/IV are approved1 |
| Efficacy Support | Limited case data only3 | Full clinical trial data1 |
| Safety Profile | Unknown bioavailability1 | Established1 |
| Recommendation | Last-resort only | First choice |
Strong Disclaimer
The patient is a 25-year-old male with recurrent CD30-negative, EBV-positive stage IV peripheral T-cell lymphoma, status post haploidentical peripheral blood stem cell transplant (PBSCT) from his sister on 2025-06-12 (Day 0). Conditioning included fludarabine, busulfan, ATG, and TBI. He is now at Day 4 post-transplant (2025-06-16), presenting with febrile neutropenia, thrombocytopenia, and gastrointestinal intolerance. Despite prophylactic antimicrobial coverage and post-transplant cyclophosphamide (Endoxan), his clinical status is complicated by high-grade fever (38.6°C), tachycardia (PR 146), hypoxia (SpO₂ 86% on room air), and rising procalcitonin (PCT 9.91 ng/mL on 2025-06-16), suggesting ongoing or worsening sepsis. Culture data are inconclusive or show likely contaminants. Supportive care includes PPN, mesna, G-CSF, and immunosuppressants (MMF, ciclosporin). Platelets and WBC remain critically low. (not posted)
Problem 1. Febrile neutropenia with respiratory compromise
Problem 2. Pancytopenia post-allo PBSCT
Problem 3. Hepatic enzyme fluctuation and renal function
Problem 4. Nutritional insufficiency with GI intolerance
[Interprofessional Practice and Family Meeting Note]
Date/Time: 2025-06-04, 10:00–11:15 Location: 11A Ward Conference Room
Chair: Dr. Gao Participants (Family): Patient, patient’s mother, eldest sister, second sister, paternal eldest uncle Participants (Medical Team): Attending physician Dr. Gao, nurse practitioner Ms. Chen, pharmacist, dietitian, psychologist, social worker
Meeting Summary:
Dr. Gao provided the patient and family with a detailed explanation of the disease course and prior treatments. The pros and cons of allogeneic transplantation were thoroughly discussed. Dr. Gao also cited literature indicating a long-term survival rate of approximately 40%, with another study showing survival curves stratified by different IPI scores. Nurse practitioner Ms. Chen inquired whether the patient had any hesitation regarding nasogastric tube placement if necessary; the patient expressed willingness to undergo NG tube placement if needed.
[Bedside Visit]
Time: 2025-06-04, 11:40
At the time of the visit, the patient’s mother had gone downstairs for lunch. The patient and his eldest sister were present in the room. I emphasized the importance of infection prevention and avoidance, as well as the critical role of supporting hematopoietic recovery during this period. Both the patient and family appeared optimistic and expressed no specific medication-related concerns during the visit.
This is a 25-year-old male with CD30-negative relapsed peripheral T-cell lymphoma (PTCL), stage IV, EBV-positive, Ki-67 index 50%, initially treated with CHOEP (2023-09 to 2024-01), then with ESHAP (from 2025-03), and currently receiving Folotyn (pralatrexate) weekly since 2025-04-23. Most recent PET (2025-05-26) demonstrates partial to complete metabolic response. He is planned for haploidentical allogeneic PBSCT on 2025-06-12. Current vitals and labs are stable. Liver enzymes, previously elevated, are improving (ALT 105 U/L on 2025-06-02 vs. peak 315 U/L on 2025-05-13). CBC parameters have also stabilized, and electrolytes, renal function, and coagulation are within acceptable range.
Problem 1. Relapsed CD30-negative Peripheral T-cell Lymphoma (Stage IV, EBV+, Ki-67 50%)
Problem 2. Hepatocellular enzyme elevation (ALT-dominant hepatopathy)
Problem 3. Electrolyte and Renal Function Status
Problem 4. Seizure Prophylaxis
Problem 5. Preparation for Allogeneic Transplant
[Phenytoin vs. Levetiracetam for Seizure Prophylaxis in Busulfan-Based Allo-PBSCT]
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| Mechanism | Blocks voltage-gated Na⁺ channels | Binds to synaptic vesicle protein SV2A, modulates NT release |
| Effect | Stabilizes neuronal membranes, suppresses seizure spread | Broad-spectrum anticonvulsant |
| Parameter | Phenytoin | Levetiracetam |
|---|---|---|
| Adult Dose | 1.25 mg/kg IV/PO every 6 hrs | 500–1000 mg IV/PO twice daily |
| Pediatric Dose | 1.25 mg/kg IV/PO every 6 hrs | 10–20 mg/kg/day IV/PO divided q12h |
| Duration | Start 1–2 days pre-busulfan; continue until 24–48 hrs post-last dose | Start 6–24 hrs pre-busulfan; continue 24–48 hrs post-last dose |
| Loading Dose | Not used in busulfan protocols | Not required |
| TDM Required | Yes (target: 10–20 µg/mL) | No |
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| Half-life | 7–42 hours (nonlinear kinetics) | 6–8 hours |
| Metabolism | Hepatic (CYP2C9, CYP2C19) | Minimal hepatic metabolism |
| Elimination | Dose-dependent hepatic clearance | Renal (unchanged drug) |
| Key Interaction | Induces CYP3A4 → ↑ busulfan clearance by 15–20% | No CYP interactions → preserves busulfan PK |
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| Busulfan Interaction | Clinically significant: Alters busulfan levels | None |
| CYP Induction | Strong inducer (CYP3A4/2C9/UGT) | None |
| Antifungal DDIs | Contraindicated with azoles (e.g., voriconazole) | Safe |
| Other DDIs | Warfarin, calcineurin inhibitors, chemotherapy | Minimal |
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| CNS Effects | Nystagmus, ataxia, cerebellar toxicity | Fatigue, irritability (rare) |
| Rash | Risk of SJS/TEN | Rare |
| Hepatotoxicity | Dose-dependent (e.g., elevated LFTs) | None |
| Monitoring | LFTs, CBC, albumin, drug levels | None |
| Metric | Phenytoin | Levetiracetam |
|---|---|---|
| Seizure Prevention | 9.3% failure rate | 100% efficacy in studies |
| Pediatric Safety | 4% seizure risk | 0% seizure risk |
| Source | Phenytoin | Levetiracetam |
|---|---|---|
| EBMT | Not recommended | Preferred agent |
| Institutional Use | Legacy protocols only | First-line in >90% of centers (2025 data) |
| Scenario | Preferred Agent | Rationale |
|---|---|---|
| All allo-PBSCT patients | Levetiracetam | Superior efficacy, no interactions, better safety |
| Hepatic impairment | Levetiracetam | No hepatic metabolism |
| Pediatrics | Levetiracetam | 0% seizure risk vs. phenytoin’s 4% |
| Phenytoin Use | Avoid unless contraindications to levetiracetam | Obsolete due to inefficacy and toxicity risks |
A point-by-point comparison of phenytoin and levetiracetam for busulfan-induced seizure prophylaxis in allo-PBSCT, supported by evidence:
Final Recommendation
Levetiracetam is the first-line choice for busulfan-induced seizure prophylaxis in allo-PBSCT, supported by:
Phenytoin should be avoided except in rare cases of levetiracetam intolerance.
References:
1 https://pmc.ncbi.nlm.nih.gov/articles/PMC6132870/ 2 https://pubmed.ncbi.nlm.nih.gov/36843563/ 3 https://pubmed.ncbi.nlm.nih.gov/36071908/ 4 https://pubmed.ncbi.nlm.nih.gov/32026356/ 5 https://pubmed.ncbi.nlm.nih.gov/33894096/ 6 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.928550/full 7 https://core.ac.uk/download/pdf/82426316.pdf 8 https://bmtctn.net/system/files/0901_MDS_AML_v5.pdf 9 https://www.sciencedirect.com/science/article/pii/S1083879119301508 10 https://www.albertahealthservices.ca/assets/info/hp/cancer/if-hp-cancer-guide-bmt-manual.pdf
[reconciliation]
Lab results on 2024-01-25 indicated normal liver and kidney function tests, with serum uric acid levels at 9.0 mg/dL, suggesting hyperuricemia. This condition is being managed with Feburic (febuxostat), and there are no discrepancies in medication.
[lab data]
2025-01-15 HLA A-high 02:07
2025-01-15 HLA A-high 11:01
2025-01-15 HLA B-high 46:01
2025-01-15 HLA B-high 55:02
2025-01-15 HLA C-high 01:02
2025-01-15 HLA C-high -
2025-01-15 HLA DQ-high 03:01
2025-01-15 HLA DQ-high 03:03
2025-01-15 HLA DR-high 09:01
2025-01-15 HLA DR-high 12:02
2024-12-03 HBsAg (NM) Negative
2024-12-03 HBsAg Value (NM) 0.410
2024-12-03 Anti-HCV (NM) Negative
2024-12-03 Anti-HCV Value (NM) 0.040
2024-12-03 Anti-HBs (NM) Negative
2024-12-03 Anti-HBs value (NM) <2.000 mIU/mL
2024-12-03 Anti-HBc (NM) Negative
2024-12-03 Anti-HBc Value (NM) 1.340
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2025-06-11 - methotrexate 15mg/m2 23mg NS 250mL 0.5hr D1 + methotrexate 10mg/m2 15mg NS 250mL 0.5hr D3,6,11
2025-06-04 - fludarabine 30mg/m2 45mg NS 250mL 1hr D1-5 + melphalan 70mg/m2 100mg NS 500mL 1hr D4-5
2024-04-15 - Vidaza (azacitidine) 75mg/m2 113mg SC D1-7
2024-03-13 - Vidaza (azacitidine) 75mg/m2 113mg SC D1-7
2024-02-11 - Vidaza (azacitidine) 75mg/m2 114mg SC D1-7
2024-01-02 - Vidaza (azacitidine) 75mg/m2 114mg SC D1-7
The patient is a post-allogeneic HSCT recipient for myelodysplastic syndrome with excess blasts II and complex cytogenetics, currently around Day +23 post-transplant (since conditioning with ATG on 2025-06-05 and methotrexate maintenance began 2025-06-11). Hematologic recovery is evident by marked leukocytosis (WBC 0.12 → 20.49 x10³/uL from 2025-06-26 to 2025-07-02), suggesting engraftment. Fever resolved, mucositis and diarrhea improved, and PCT remains low (0.16 ng/mL on 2025-07-02). Persistent anemia and thrombocytopenia remain. No CMV reactivation noted. Renal and liver function are preserved.
Problem 1. Post-HSCT engraftment and hematologic recovery
Problem 2. Infection status and anti-infective management
Problem 3. Immunosuppression monitoring
Problem 4. Cytopenias: persistent thrombocytopenia and anemia
Problem 5. CMV infection prophylaxis consideration
Key Insight / Summary
Problem 1. Myelodysplastic Syndrome (RAEB-II) Post-Allo-HSCT
Problem 2. Infection Risk and Management (Neutropenic Fever)
Problem 3. Persistent Pancytopenia
Problem 4. Nutrition and Diarrhea (not posted)
Problem 5. Electrolyte and Renal Function Monitoring (not posted)
Problem 6. Antiviral Prophylaxis: CMV
Problem 7. CMV prophylaxis after allo-HSCT
Objective
Assessment
According to NHI rule 10.7.12, this patient meets all eligibility criteria for letermovir use:
The absence of Prevymis during this early vulnerable period may increase CMV reactivation risk.
Recommendation
Initiate Prevymis (letermovir) as CMV prophylaxis pending prior authorization.
Monitor weekly CMV PCR assays to assess for breakthrough viremia.
Re-evaluate drug interactions, especially with cyclosporin (dose adjustment not required but close monitoring needed).
a “CMV viral load: Target Not Detected” on 2025-06-25 is not a sufficient reason to omit anti-CMV prophylaxis in this patient.
Conclusion:
The patient is in the post-conditioning phase following allogeneic PBSCT for MDS-RAEB-II with complex cytogenetics. As of 2025-06-23, he remains severely pancytopenic (WBC 0.03, PLT 19, HGB 8.9), with ongoing grade 2 oral mucositis and persistent candidiasis. No evidence of invasive fungal disease or active bacterial infection is found (PCT 0.05 ng/mL on 2025-06-16, stable vitals). Supportive care includes broad-spectrum antimicrobials (meropenem, teicoplanin, micafungin), G-CSF, PPN, and ciclosporin. Renal and hepatic function are stable. Despite mucositis and intermittent diarrhea, his general status remains ECOG 1.
Problem 1. Persistent Severe Pancytopenia Post-Allo PBSCT
Problem 2. Febrile Neutropenia with Broad-Spectrum Antimicrobial Use
Problem 3. Mucositis and Oral Candidiasis
Problem 4. Electrolyte and Nutritional Support in the Setting of Diarrhea
Problem 5. Immunosuppressive Therapy with Ciclosporin
Problem 6. CMV prophylaxis post-allo-HSCT: consider need for Prevymis (letermovir)
The 69-year-old male with myelodysplastic syndrome with excess blasts II and complex cytogenetics has completed conditioning (fludarabine, melphalan, ATG), received methotrexate post-transplant (2025-06-11 D+1), and underwent allo-PBSCT on 2025-06-10. Febrile neutropenia and elevated PCT (11.47 ng/mL on 2025-06-09) prompted broad-spectrum antibiotics and antifungal coverage. Diarrhea developed, requiring parenteral nutrition. As of 2025-06-16, he remains afebrile with ECOG 1 and no new mucosal lesions; candidiasis is present. WBC remains at 0.02 ×10³/uL with 0% neutrophils; Procalcitonin normalized to 0.05 ng/mL. Renal and liver functions are preserved.
Problem 1. Profound neutropenia post-allo-PBSCT
Problem 2. Recent sepsis with successful microbial control
Problem 3. Diarrhea and nutritional support
Problem 4. Mucositis and candidiasis
Problem 5. Hepatic function alteration (possible DILI) (not posted)
Patient Summary
Problem 1. Febrile neutropenia and sepsis suspicion
Problem 2. Pancytopenia post-conditioning (pre-transplant Day -1)
Problem 3. Electrolyte and renal function monitoring under chemotherapy
Active Medication Review
Problem 1. Transfusion-dependent anemia and thrombocytopenia
Problem 2. Suboptimal hematologic response to Vidaza (azacitidine)
Problem 3. Iron overload secondary to transfusion
Problem 4. Stable renal and hepatic function
Problem 5. Disease status: MDS-IB2 without AML transformation
[Anemia and Thrombocytopenia Evaluation]
Objective Findings
Assessment
Recommendations
[Evaluation of Vidaza (azacitidine) Treatment Effect]
Objective Findings
Assessment of Vidaza Efficacy
Recommendations
Final Summary
[Evaluation of Treatment Alignment with NCCN Guidelines for Myelodysplastic Syndromes (MDS)] (not posted)
Does the treatment align with NCCN Guidelines?
Why does it align?
Appropriate for High-Risk MDS: The NCCN guidelines recommend hypomethylating agents (HMAs) such as azacitidine or decitabine as a standard first-line therapy for higher-risk MDS, particularly for patients ineligible for hematopoietic stem cell transplantation (HCT).
Standard Dosing: The dosage and schedule of azacitidine 75 mg/m² SC D1-7 Q4W is consistent with NCCN recommendations.
Alternative to HCT in High-Risk Cases: Allogeneic hematopoietic cell transplantation (HCT) is the only curative therapy but is typically reserved for younger, fit patients. Given the patient’s cytogenetic profile (complex karyotype: -5, -7, -12, -17, der(20)t(17;20)), high-risk status, and the use of azacitidine, the treatment plan is within guideline-based options.
Consideration of Emerging Therapy: The guidelines also mention combination therapy with azacitidine + venetoclax for patients with higher-risk MDS. While venetoclax is not currently included in this patient’s regimen, its use is suggested in patients with refractory disease or high blast counts.
Additional Considerations:
Conclusion
[Cytogenetic Analysis]
Cytogenetic Analysis Interpretation:
This cytogenetic profile provides critical prognostic and therapeutic insights:
Final Summary
[Patient Summary]
The patient is a 69-year-old male with myelodysplastic syndrome (MDS) with refractory anemia and excess of blasts II. Diagnosed with a complex cytogenetic profile (3843,XY,-5,-7,-12,der(14)t(11;14)(q13;p11.2),-17,-17,der(20)t(17;20)(q11.2;q11.2),+12mar[cp8]∕46,XY1) on 2024-12-09, he has been experiencing progressive pancytopenia with macrocytic anemia since 2024-11-29, requiring frequent transfusions. His treatment was initiated with Vidaza (azacitidine) on 2025-01-02 for a planned 7-day regimen monthly for 4 months. Significant findings include pancytopenia with blasts (~15% on bone marrow biopsy, 2024-12-09) and stable vital signs. Key challenges include cytopenias and a complex karyotype with a p53 mutation, both of which carry a poor prognosis.
[MDS Comments]
Problem: Myelodysplastic Syndrome with Refractory Anemia and Excess of Blasts II (MDS-IB2)
[Evaluation for Anemia and Thrombocytopenia]
Objective
Assessment
Recommendations
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[consultation]
[Subjective]
medication adherence and perception
symptom status
[Objective]
medication list
vital signs and labs
[Assessment]
heart failure with reduced ejection fraction (HFrEF)
gout and uric acid control
renal protection and monitoring
patient engagement and adherence
[Plan / Recommendation]
optimize heart failure pharmacotherapy
renal and electrolyte monitoring
gout management
lipid and vascular protection
education and follow-up
This 55-year-old male was admitted on 2025-06-19 with exertional dyspnea and elevated BP (181/137 mmHg), diagnosed with acute decompensated heart failure with reduced ejection fraction (HFrEF, LVEF 27%), dilated cardiomyopathy, and suspected ischemic cardiomyopathy. Imaging revealed global LV hypokinesia, moderate-to-large pericardial effusion, and grade III diastolic dysfunction. Serial hsTnI were mildly elevated; NT-proBNP peaked at 5378.9 pg/mL. His clinical course improved after IV diuretics and guideline-directed medical therapy (ARNI, beta-blocker, SGLT2 inhibitor, MRA). He was discharged on 2025-06-27 and was stable at follow-up on 2025-07-01 with NYHA class III symptoms improving. Issues of note include moderate LV systolic dysfunction, pulmonary hypertension, gout flare, CKD stage 3, mild transaminitis, and hyperuricemia.
Problem 1. Heart failure with reduced ejection fraction (HFrEF)
Problem 2. Ischemic heart disease / prior infarction
Problem 3. Moderate to large pericardial effusion
Problem 4. Chronic kidney disease (CKD) stage 3
Problem 5. Gouty arthritis flare
Problem 6. Electrolyte and acid-base balance
GDMT stands for Guideline-Directed Medical Therapy.
In the context of heart failure, GDMT refers to the use of medications and interventions that are recommended by clinical practice guidelines (such as those from the American College of Cardiology [ACC], American Heart Association [AHA], and European Society of Cardiology [ESC]) based on strong evidence to improve outcomes in patients.
For HFrEF (Heart Failure with Reduced Ejection Fraction), GDMT typically includes:
These therapies have been shown to reduce mortality and hospitalizations in patients with HFrEF.
[exam finding]
[MedRec]
[consultation]
[Subjective]
Medication use and concerns reported by family
Follow-up discussion reminders suggested for next physician visit
[Objective]
Current medication list
Relevant labs and findings
[Assessment]
Potential drug-drug interaction: esomeprazole and clopidogrel
Inadequate thyroid replacement therapy
Suboptimal glycemic control
[Plan / Recommendation]
Address possible clopidogrel-PPI interaction
Reassess levothyroxine dose
Evaluate need for glucose-lowering therapy
Monitor for adverse effects and adherence
Document communication
This is a 74-year-old man with a complex cardiovascular and systemic background, notably:
Problem 1. Coronary artery disease with recent NSTEMI and PCI
Problem 2. Heart failure with reduced ejection fraction (HFrEF)
Problem 3. Chronic kidney disease stage 3b
Problem 4. Bradyarrhythmia and PVCs
Problem 5. Hypothyroidism (post-subtotal thyroidectomy)
Problem 6. Dyslipidemia
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
This is a 72-year-old woman with small cell B-cell lymphoma (likely marginal zone subtype), Lugano stage IV involving lymph nodes and bone marrow. Since diagnosis via bone marrow biopsy on 2024-01-02, she has received R-COP chemotherapy (C1–C5) with good tolerance. Imaging (CT 2025-06-20) shows partial response with regression of lymphadenopathy. Concurrent medical issues include paroxysmal atrial fibrillation (s/p ablation on 2025-01-09), CKD stage 3, normocytic anemia, past pulmonary edema with preserved EF, and intermittent eczema.
She began R-COP on 2025-07-01 this hospital stay under stable hemodynamic and biochemical status. Recent blood and metabolic panels suggest partial hematologic improvement, stable renal and liver function, and resolution of previously elevated inflammatory parameters. No fever, edema, or active infection is observed. She remains ECOG PS 1.
Problem 1. Small B-cell lymphoma, Lugano stage IV
Problem 2. Anemia (normocytic, chronic)
Problem 3. Chronic kidney disease (stage 3)
Problem 4. Cardiovascular comorbidity: paroxysmal atrial fibrillation, HFpEF
Problem 5. Dermatologic condition: eczema (not posted)
This is a 72-year-old woman with small B-cell lymphoma (likely marginal zone lymphoma), Lugano stage IV with bone marrow involvement, undergoing immunochemotherapy with R-COP regimen. She also has a history of paroxysmal atrial fibrillation (s/p 4PVI and CTI ablation on 2025-01-09), heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD) stage 3, moderate to severe mitral regurgitation, and normocytic anemia.
Despite stable coronary arteries (CAG 2024-05-03), she experienced recurrent pulmonary edema (CXR 2025-01-25) and rising BUN/Cr with anemia progression. She recently received R-COP (2025-03-31) under a stable but borderline condition. Labs show worsening anemia, persistent leukocytosis, and rising inflammatory markers (CRP, PCT). Imaging shows stationary paraaortic lymphadenopathy and newly noted axillary and cervical LNs (CT 2025-02-10).
Problem 1. Hematologic Malignancy - Small B-cell Lymphoma, Lugano Stage IV
Problem 2. Normocytic Anemia
Problem 3. Heart Failure and Arrhythmia (AF, MR, HFpEF)
Problem 4. Chronic Kidney Disease, Stage 3 (below not posted)
Problem 5. Inflammatory and Infectious Monitoring
[lab data]
2024-02-07 Cryoglobulin Positive
2023-10-23 Cryoglobulin Positive
2023-06-02 HBsAg (NM) Negative
2023-06-02 HBsAg Value (NM) 0.438
2023-06-02 Anti-HCV (NM) Negative
2023-06-02 Anti-HCV Value (NM) 0.040
2023-06-02 Anti-HBc (NM) Positive
2023-06-02 Anti-HBc Value (NM) 0.009
2023-06-02 Anti-HBs (NM) Positive
2023-06-02 Anti-HBs value (NM) 18.200 mIU/mL
2022-02-04 Anti-HBc Reactive
2022-02-04 Anti-HBc-Value 7.63 S/CO
2022-02-04 Anti-HBs 31.17 mIU/mL
2022-02-04 HBsAg Nonreactive
2022-02-04 HBsAg Value 0.00 IU/mL
2022-02-04 Anti-HCV Nonreactive
2022-02-04 Anti-HCV Value 0.07 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 55-year-old woman with recurrent HPV-associated vaginal adenocarcinoma (FIGO stage I, pT1aNx) involving the vaginal stump and urinary bladder wall, previously treated with surgery, radiotherapy, and currently on Avastin (bevacizumab) plus paclitaxel/carboplatin chemotherapy (16 cycles to date, 2025-06-04 being the latest). She has multiple chronic comorbidities including type 2 diabetes mellitus, resolved hepatitis B, hypomagnesemia, and hyperlipidemia. She remains ECOG 1 with stable weight and vitals.
Disease status is clinically stable with no major new complications, but persistent urinary tract infection and chemotherapy-induced cytopenia warrant close monitoring.
Problem 1. Recurrent HPV-associated vaginal adenocarcinoma (FIGO stage I, pT1aNx)
Problem 2. Chronic urinary tract infection (likely complicated UTI) (not posted)
Problem 3. Chemotherapy-related cytopenia
Problem 4. Type 2 diabetes mellitus
Problem 5. Chronic hepatitis B (resolved) and liver monitoring
Problem 6. Hypomagnesemia
Patient Evaluation:
Problem 1. Recurrent Neutropenia (Managed with G-CSF)
Problem 2. Mild Anemia (Stable Trend) (not posted)
Problem 3. Cryoglobulinemia (Now Resolved)
Problem 4. Mild Electrolyte Fluctuations (not posted)
Final Summary (not posted)
[Granocyte and blood glucose monitoring recommendations]
Granocyte (lenograstim) is scheduled for 3 consecutive days to treat the patient’s neutropenia (WBC 2.33 x10^3/uL on 2024-07-31).
Serum glucose levels were recorded at 236 mg/dL on the morning of 2024-04-11 on the TPR panel. However, there are no recent HbA1c or serum glucose (AC) data available in the HIS5 lab panel. It is recommended that these tests be conducted routinely for better blood glucose monitoring and control.
[considering hypoglycemic adjustment for elevated glucose; normal liver enzymes and potential cessation of baogan]
A CT scan conducted on 2024-04-08 revealed a suspected cystic tumor at the vaginal stump and hepatic tumors appeared unchanged. Subsequent lab tests on 2024-04-10 showed no significant abnormalities.
However, serum glucose levels, recorded at 293 mg/dL on the morning of 2024-04-11, were elevated despite current treatment with Forxiga (dapagliflozin) and Kludone (gliclazide). Should these high glucose levels persist, there may be a need to consider additional hypoglycemic agents to manage the patient’s condition.
Given the AST and ALT levels have remained within the normal range for several weeks, discontinuation of BaoGan (silymarin) might be considered.
[reconciliation]
A refill for a 28-day quantity of Omeprotect (omeprazole) and Dulcolax (bisacodyl) was recently completed on 2023-08-05, but these medications are currently not listed in the active medication records. Kindly assess whether these drugs are no longer required for the patient.
[reconciliation]
On 2023-07-08, the patient just refilled a 28-day supply of Omeprotect (omeprazole) and Dulcolax (bisacodyl), and on 2023-07-10 refilled a 30-day supply of Anxoken (metformin), Kludone (gliclazide), and Forxiga (dapagliflozin). However, metformin is currently absent from the active medication list, and a serum glucose level of 341mg/dL was recorded on 2023-07-19 at 16:16. It is advisable to determine if the omission of metformin is deliberate or due to the scheduling of a CT scan.
[exam finding]
[MedRec]
[consultation]
This is a 64-year-old male with newly diagnosed right middle lobe adenocarcinoma of the lung, cT4N3M1c2 stage IVB (PET 2025-06-16), complicated by malignant right pleural effusion, right pneumothorax s/p pigtail, and extensive metastases (pleura, contralateral lung, liver, adrenal glands, bone, lymph nodes). The tumor is PD-L1 negative, with no actionable EGFR, ALK, or ROS1 mutations. He has comorbid COPD, type 2 diabetes mellitus (with fluctuating hyperglycemia), hypertension, hyperlipidemia, and a history of ICH in 2020. Performance status remains relatively preserved with stable vitals and no desaturation. Current management is supportive and diagnostic; systemic treatment plan not yet finalized.
Problem 1. Advanced lung adenocarcinoma with widespread metastases (cT4N3M1c2)
Problem 2. Type 2 diabetes mellitus with fluctuating hyperglycemia
Problem 3. Respiratory compromise with right pleural effusion and pneumothorax
Problem 4. Hepatitis B serostatus and reactivation risk
Problem 5. Hyponatremia (mild, new onset) (not posted)
[lab data]
2025-06-14 HBsAg Nonreactive
2025-06-14 HBsAg Value 0.28 S/CO
2025-06-14 Anti-HBc Reactive
2025-06-14 Anti-HBc Value 5.21 S/CO
2025-06-14 Anti-HCV Nonreactive
2025-06-14 Anti-HCV Value 0.16 S/CO
[exam finding]
[surgical operation]
The patient, a 72-year-old male with newly diagnosed metastatic poorly differentiated carcinoma (TTF-1 positive) of right neck lymph node origin (likely lung primary), presented with progressive neurological deterioration marked by multiple embolic infarcts and large bilateral PCA territory hemorrhagic transformation (MRA 2025-06-15). Over the recent days, consciousness has further declined (GCS 2025-06-30: E3V3M4), with stable vital signs but worsening intracranial hemorrhage (CT 2025-06-29). Concomitantly, the patient demonstrates DIC features with persistently elevated D-dimer (>10000 ng/mL FEU 2025-06-27), hypofibrinogenemia (99.6 mg/dL 2025-06-27), and thrombocytopenia (PLT 69 x10^3/uL 2025-06-29). Electrolytes show mild hypokalemia and hypernatremia, while renal function remains stable. Blood glucose fluctuates (peak 233 mg/dL 2025-06-28) under ongoing insulin therapy.
Problem 1. Neurological deterioration with PCA infarction and hemorrhage
Problem 2. Disseminated intravascular coagulation (DIC)
Problem 3. Hyperglycemia in context of steroid therapy and stress
[lab data]
2025-02-05 Anti-HBc Reactive
2025-02-05 Anti-HBc Value 6.48 S/CO
2025-02-04 Anti-HBc IgM Nonreactive
2025-02-04 Anti-HBc IgM Value 0.08 S/CO
2025-02-03 Anti-HCV Nonreactive
2025-02-03 Anti-HCV Value 0.07 S/CO
2025-02-03 HBsAg Nonreactive
2025-02-03 HBsAg Value 0.38 S/CO
2025-02-03 Anti-HBs 22.60 mIU/mL
2025-02-03 HIV Ab EIA Nonreactive
2025-02-03 Anti-HIV Value 0.05 S/CO
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
The patient is a 69-year-old woman with stage IVB small round blue cell tumor of the right lung with metastases to liver and bone. She was hospitalized due to progressive dyspnea and generalized weakness. Imaging on 2025-07-01 and 2025-07-12 revealed stable mediastinal tumor burden but progression of pleural effusion, hepatic, and skeletal metastases. She underwent pigtail drainage and initiated systemic therapy with durvalumab, carboplatin, and etoposide on 2025-07-08. Complicating issues include hyponatremia, hepatic dysfunction (transaminase and bilirubin elevations), anemia, and hypoalbuminemia. There is no HBV flare (HBV DNA <10 IU/mL on 2025-07-04). Shared decision-making confirmed willingness to continue anticancer treatment.
Problem 1. Metastatic small round blue cell tumor with pleural and hepatic involvement
Problem 2. Pleural effusion and respiratory compromise
Problem 3. Liver dysfunction with elevated AST/ALT and bilirubin
Problem 4. Normocytic anemia and thrombocytopenia
Problem 5. Electrolyte imbalance: hyponatremia
The patient is a 69-year-old female with advanced small cell lung cancer (RUL), stage IVB (cT4N3M1c2), with known liver and bone metastases, now complicated by worsening right pleural effusion and progressive general weakness. Current labs reveal worsening liver dysfunction (elevated AST/ALT and bilirubin on 2025-06-30), persistent anemia (HGB 9.1 g/dL on 2025-06-30), thrombocytopenia (PLT 143 x10^3/uL on 2025-06-30), and electrolyte disturbances (hypokalemia). Her respiratory function is compromised with documented hypoxia (SpO2 92% on 2025-06-30). She also exhibits signs of hepatic injury progression compared to prior data.
Problem 1. Hepatic dysfunction and liver metastasis progression
Problem 2. Anemia and thrombocytopenia
Problem 3. Electrolyte disturbances and renal function
Problem 4. Respiratory compromise with right pleural effusion
[lab data]
2024-05-24 HBV-DNA-PCR Target Not Detected IU/mL
2023-09-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-09-11 HBsAg Nonreactive
2023-09-11 HBsAg Value 0.49 S/CO
2023-09-11 Anti-HCV Nonreactive
2023-09-11 Anti-HCV Value 0.12 S/CO
2023-09-11 Anti-HBc Reactive
2023-09-11 Anti-HBc Value 5.99 S/CO
2020-10-31 HIV Ab-EIA Nonreactive
2020-10-31 Anti-HIV Value 0.06 S/CO
2020-10-31 Anti-HCV Nonreactive
2020-10-31 Anti-HCV Value 0.13 S/CO
2020-10-31 Anti-HAV IgG Reactive
2020-10-31 Anti-HAV IgG Value 10.02 S/CO
2020-10-31 HBsAg Nonreactive
2020-10-31 HBsAg Value 0.36 S/CO
2020-10-31 Anti-HAV IgM Nonreactive
2020-10-31 Anti-HAV IgM Value 0.47 S/CO
[exam findings]
2025-05-30 CT - abdomen
2025-04-29 Pathology - stomach biopsy
2025-04-29 Esophagogastroduodenoscopy, EGD
2025-04-24 Nasopharyngoscopy
2025-04-02 Nasopharyngoscopy
2025-03-03 CT - abdomen
2025-02-10 Sonography - abdomen
2025-02-03 PTCD (percutaneous transhepatic cholangial drainage) revision
2025-01-02 2D transthoracic echocardiography
2024-12-10 CXR
2024-12-06 Body fluid cytology - ascites
2024-12-03 CT - abdomen
2024-12-02 Abdomen - Standing (Diaphragm)
2024-12-02 Paracentesis
2024-11-28 CXR
2024-11-27 PTCD (percutaneous transhepatic cholangial drainage) revision
2024-11-08 CT - abdomen
2024-11-07 CXR
2024-11-07, -11-03 Abdomen - Standing (Diaphragm)
2024-08-28 CT - abdomen
2024-07-30 CXR
2024-05-24 PTCD (percutaneous transhepatic cholangial drainage)
2024-05-18 CT - abdomen
2024-04-02 Nerve Conduction Velocity, NCV
2024-04-02 Nerve Conduction Velocity, NCV
2024-02-19 Tc-99m MDP bone scan with SPECT
2024-02-17 CT - abdomen
2024-01-24 Patho - stomach biopsy
2024-01-24 EGD
2024-01-23 MRI - brain
2023-12-14 ENT Hearing Test
2023-11-14 CT - abdomen
2023-08-29 Patho - liver partial resection
2023-08-14 PET
2023-07-19 CT - abdomen
2023-07-04 SONO - abdomen for follow-up
2023-03-30 Patho - liver partial resection
2023-03-17 CT - abdomen
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-06-26 - pembrolizumab 200mg NS 100mL 1hr + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-06-02 - pembrolizumab 200mg NS 100mL 1hr (Keytruda)
2025-05-29 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-05-13 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 3530mg NS 500mL 46hr (80%)
2025-04-24 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-04-07 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-03-31 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-02-27 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-02-07 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-01-17 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2024-12-31 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
2024-12-03 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
2024-11-04 - nivolumab 240mg NS 100mL 1hr + carboplatin AUC 2 250mg NS 250mL 2hr D1 + topotecan 1.5mg/m2 2mg D5W 60mL 30min D1-4
2024-10-09 - nivolumab 240mg NS 100mL 1hr + carboplatin AUC 2 250mg NS 250mL 2hr D1 + topotecan 1.5mg/m2 2mg D5W 60mL 30min D1-4
2024-09-16 - nivolumab 240mg NS 100mL 1hr + carboplatin AUC 2 250mg NS 250mL 2hr D1 + topotecan 1.5mg/m2 2mg D5W 60mL 30min D1-4
2024-08-26 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90%)
2024-08-09 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90%)
2024-07-23 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90% due to WBC 2890, ANC 1757)
2024-07-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
2024-06-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
2024-05-28 - leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-05-27 - topotecan 1.5mg/m2 2.5mg D5W 80mL 30min D1-4 + carboplatin AUC 2 250mg NS 250mL 2hr D1
2024-02-16 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 120mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 155mg NS 500mL 2hr D1-3
2024-01-24 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
2024-01-02 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
2023-12-11 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
2023-11-13 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 145mg NS 500mL 2hr D1-3
2023-10-23 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 145mg NS 500mL 2hr D1-3
2023-10-03 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 120mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 160mg NS 500mL 2hr D1-3
2023-09-11 - NS 1000mL 4hr (before CDDP) + furosemide 20mg (after NS) + cisplatin 70mg/m2 105mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) + furosemide 20mg (after NS) + etoposide 100mg/m2 150mg NS 500mL 2hr D1-3
The patient is a 59-year-old woman with stage IV gallbladder neuroendocrine carcinoma with liver metastases (pT2aN0M1), post resection and multiple chemotherapy regimens (CDDP+VP-16 ×8, Topotecan/Carboplatin, FOLFOX, now FOLFIRI + Lenvima + Pembrolizumab). The disease status is currently stable (CT 2025-05-30). Despite multiple prior progressions, the patient remains functionally preserved (G1 fatigue) with tolerable adverse events from therapy. Current issues include worsening hyperbilirubinemia, G2 hepatic enzyme elevation, G3 thrombocytopenia, G2 peripheral neuropathy, and G1 gastrointestinal and hematologic toxicities. The patient is on cycle 6 FOLFIRI with concurrent pembrolizumab and lenvatinib.
Problem 1. Hyperbilirubinemia and Hepatic Dysfunction
Problem 2. Chemotherapy-Induced Thrombocytopenia (Grade 3)
Problem 3. Gallbladder Neuroendocrine Carcinoma with Liver Metastases (Stable Disease)
Problem 4. Electrolyte and Nutritional Imbalances (not posted)
Problem 5. Chemotherapy-Related Sensory Neuropathy (Grade 2)
This 59-year-old female with gallbladder neuroendocrine carcinoma, high grade, pT2aN0M1, stage IV post-S5/S4b resection (2023-08-28), has undergone extensive lines of chemotherapy (CDDP + VP-16 x8, FOLFOX, Topotecan/Carboplatin/Nivolumab, now FOLFIRI) and targeted therapy Lenvima (lenvatinib), with confirmed progressive liver and peritoneal metastasis. She was recently admitted (2025-05-29 to 2025-06-02) for FOLFIRI C5D15 and received pembrolizumab 200mg on 2025-06-02. On this date, lab showed Grade 3 thrombocytopenia (PLT 44 x10^3/uL), Grade 2 anemia (Hb 8.6 g/dL), and leukopenia (WBC 2.00 x10^3/uL). Transfusion of LPRBC was arranged. Vital signs were stable (BP 127/68 mmHg, Temp 36.9°C), and she remained afebrile with PS 1 (ECOG). CT on 2025-05-30 suggested stable hepatic and peritoneal disease, despite mild progression of one lesion.
Problem 1. Gallbladder neuroendocrine carcinoma with liver and peritoneal metastases, pT2aN0M1, stage IV
Problem 2. Chemotherapy-induced pancytopenia (anemia, thrombocytopenia, leukopenia)
Problem 3. Hepatic dysfunction and HBV carrier status
Problem 4. Chemotherapy-related gastrointestinal complications
[Key Findings]
Systemic Disease Progression
Primary diagnosis: Gallbladder neuroendocrine carcinoma, high-grade (initially pT2aN0, now stage IV).
Current progression:
Liver Function and Tumor Markers
Hematology and Bone Marrow Function
Anemia of chronic disease:
Thrombocytopenia resolved: PLT increased to 164 x 10^3/uL (2024-11-27) compared to critically low 45 x 10^3/uL (2024-10-16), likely reflecting marrow recovery after prior chemotherapy-induced myelosuppression.
Leukopenia stable: WBC 4.78 x 10^3/uL (2024-11-27).
CNS and Neurological Findings
Current Chemotherapy and Responses
Complications and Supportive Issues
Portal hypertension: Manifesting as splenomegaly, spontaneous shunt, and ascites.
PTCD dysfunction: Likely recurrent obstruction due to bile duct compression.
Nutritional status:
Comprehensive Status Assessment
[Current Active Medications Review]
Medications for Symptom Management
Medications for Hepatic and Biliary Support
Medications for Cardiovascular and Metabolic Conditions
Medications for Nutritional Support and Anemia
[stable WBC and improved bilirubin levels under FOLFOX]
Since the chemotherapy started in late May, WBC levels have consistently remained above 2.5K/uL, with no severe neutropenia occurring. The current FOLFOX regimen is being administered at 90% of the standard dose.
The elevated conjugated bilirubin levels have shown a downward trend, indicating improvement.
Additionally, there has been no recent elevation in CEA, and the CA199 spike observed in late July has decreased by mid-August.
Overall, the treatment appears to be effective, with no major adverse reactions and an improvement in jaundice symptoms. No medication issues have been identified.
2024-08-25 WBC 2.69 x10^3/uL
2024-08-20 WBC 3.32 x10^3/uL
2024-08-09 WBC 2.86 x10^3/uL
2024-08-07 WBC 3.95 x10^3/uL
2024-07-30 WBC 5.60 x10^3/uL
2024-07-23 WBC 2.89 x10^3/uL
2024-07-17 WBC 2.93 x10^3/uL
2024-07-03 WBC 2.98 x10^3/uL
2024-06-24 WBC 3.61 x10^3/uL
2024-06-20 WBC 6.35 x10^3/uL
2024-06-18 WBC 4.75 x10^3/uL
2024-06-16 WBC 4.62 x10^3/uL
2024-06-12 WBC 10.93 x10^3/uL
2024-06-03 WBC 2.68 x10^3/uL
2024-05-30 WBC 3.89 x10^3/uL
2024-05-27 WBC 4.73 x10^3/uL
2024-08-25 Bilirubin direct 0.32 mg/dL
2024-08-09 Bilirubin direct 0.29 mg/dL
2024-07-23 Bilirubin direct 0.43 mg/dL
2024-06-24 Bilirubin direct 0.47 mg/dL
2024-06-20 Bilirubin direct 0.65 mg/dL
2024-06-18 Bilirubin direct 0.77 mg/dL
2024-06-16 Bilirubin direct 1.66 mg/dL
2024-06-03 Bilirubin direct 1.10 mg/dL
2024-05-30 Bilirubin direct 1.40 mg/dL
2024-05-27 Bilirubin direct 1.83 mg/dL
2024-05-23 Bilirubin direct 4.71 mg/dL
2024-08-13 CA-199 (NM) 60.189 U/ml
2024-07-22 CA-199 (NM) 104.381 U/ml
2024-07-09 CA-199 (NM) 77.640 U/ml
2024-06-14 CA-199 (NM) 47.320 U/ml
[Post-PTCD Concerns: Elevated Bilirubin & Rising CA-199 Marker]
Recent PTCD and Follow-up Concerns: The patient recently underwent percutaneous transhepatic cholangiodrainage (PTCD) on 2024-05-24. However, her total bilirubin level has since risen to 2.71 mg/dL. This elevation may warrant consideration of another PTCD procedure if symptoms reappear.
2024-06-16 Bilirubin total 2.71 mg/dL
2024-06-12 Bilirubin total 1.62 mg/dL
2024-06-03 Bilirubin total 1.96 mg/dL
2024-06-16 Bilirubin direct 1.66 mg/dL
2024-06-03 Bilirubin direct 1.10 mg/dL
Rising CA-199 Marker:
Additionally, the patient’s CA-199 tumor marker level appears to be increasing.
[drug identification]
Since the drug to be identified is an unpackaged tablet, its quality and expiration date cannot be confirmed, so the response is that the drug cannot be identified.
An in-hospital porter will be sent to deliver the tablets to the ward.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 66-year-old woman has stage IVB right middle lobe lung adenocarcinoma (cT4N2M1c), EGFR exon 19 deletion (+), PD-L1 negative, with known brain metastases and newly suspected bone metastasis. She is currently receiving dual anti-EGFR therapy with oral “Giotrif (afatinib)” and IV “Rybrevant (amivantamab)”, combined with “Avastin (bevacizumab)” as angiogenesis inhibitor, with evidence of tumor regression on CT (2025-06-14). She has complications including idiopathic left-sided sudden hearing loss (progressive SNHL), pyogenic granulomas, internal hemorrhoids requiring ligation, and eczema/angioedema. Supportive medications include proton pump inhibitors, antihistamines, topical antibiotics, and emollients. Labs are stable with mild hyponatremia. Comorbidities include hypertension, hyperlipidemia, resolved HBV infection (on prophylactic “Vemlidy (tenofovir alafenamide)”). Overall disease is partially responsive, but symptom burden remains moderate.
Problem 1. Right middle lobe lung adenocarcinoma, cT4N2M1c stage IVB, EGFR exon 19(+), PD-L1(-)
Problem 2. Left sudden idiopathic sensorineural hearing loss (SNHL)
Problem 3. Pyogenic granuloma and dermatologic manifestations
Problem 4. Internal hemorrhoids
Problem 5. Electrolyte abnormalities
Problem 6. Resolved HBV infection with antiviral prophylaxis
[MedRec]
This is a 74-year-old male with metastatic prostate adenocarcinoma (diagnosed 2022), who has progressed through androgen deprivation, enzalutamide, radiation, and docetaxel/cisplatin, and was started on olaparib in 2025-04 based on FoundationOne NGS. In 2025-05, the patient developed T7–T11 spinal cord compression and paraplegia, requiring emergent decompressive laminectomy with significant intraoperative bleeding and persistent postoperative paraplegia. Palliative radiotherapy was halted due to severe pancytopenia. He was admitted on 2025-06-23 for supportive care, pain management, and hospice planning. Current labs show pancytopenia (HGB 7.3 g/dL, PLT 44 x10³/uL, WBC 2.97 x10³/uL), hypoalbuminemia (2.7 g/dL), and hypocalcemia (1.81 mmol/L), but preserved renal (Cr 1.14 mg/dL, eGFR 66.93 mL/min/1.73m²) and liver function (ALT 18 U/L, AST 17 U/L) (labs 2025-06-23). He is receiving multimodal analgesia including Duragesic (fentanyl) patch, OxyContin (oxycodone), and PRN Morphine, with adequate but guarded control.
Problem 1. Advanced metastatic prostate adenocarcinoma with spinal cord compression
Objective
Assessment
Recommendation
Problem 2. Severe anemia and thrombocytopenia (transfusion-dependent pancytopenia)
Problem 3. Pain management in paraplegic terminal cancer patient
Problem 4. Nutritional and metabolic derangements
[Medication Reconciliation]
Date: 2025-06-24 Patient: 74-year-old male with metastatic prostate adenocarcinoma, extensive bony metastases, post-spinal cord compression (T7–T11) with paraplegia Current Status: Admitted 2025-06-23 for pain control and hospice evaluation; receiving multiple supportive medications.
Summary of Discrepancies and Recommendations:
Additional Monitoring Suggestions:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 69-year-old male with a diagnosis of moderately differentiated right buccal mucosa squamous cell carcinoma (pT3N0M0, Stage III) status post wide excision, selective neck dissection, and split-thickness skin graft on 2025-04-11. He is currently undergoing concurrent chemoradiotherapy with weekly cisplatin since 2025-05-15 and has received 5000 cGy/25 fractions as of 2025-06-19. He presents with neutropenic sepsis secondary to right lower lobe pneumonia, with complications including grade 3 neutropenia, thrombocytopenia, elevated CRP, and ongoing dizziness. His performance status is ECOG 2 (2025-06-24), and he remains hemodynamically stable on current therapy.
Problem 1. Neutropenic Sepsis with Aspiration Pneumonia
Problem 2. Head and Neck Cancer (Right Buccal SCC pT3N0M0, Stage III) s/p Surgery and Ongoing CCRT
Problem 3. Myelosuppression (Neutropenia and Thrombocytopenia)
Problem 4. Electrolyte Abnormalities and Malnutrition
Problem 5. Cardiovascular Status and LV Dysfunction
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 71-year-old woman with diffuse large B-cell lymphoma (DLBCL), germinal center B-cell (GCB) subtype, Lugano stage III, continues chemotherapy with R-CHOP, receiving 6 cycles as of 2025-06-19. The overall status is stable with ECOG 1 and adequate organ function. She experienced neutropenic fever after Cycle 5 but recovered. Her recent labs (2025-06-19) show resolution of neutropenia, stable anemia, and no evidence of acute liver, renal, or infectious complications. She remains on Vemlidy (tenofovir alafenamide) for chronic hepatitis B prophylaxis and is tolerating chemotherapy.
Problem 1. Diffuse Large B-Cell Lymphoma, GCB Subtype (Stage III, CD10+, Ki-67 >90%)
Problem 2. Chemotherapy-Related Cytopenias (Neutropenia and Anemia)
Problem 3. Infection Risk and Status Post-Neutropenic Fever (not posted)
Problem 4. Hepatitis B Reactivation Risk Under Rituximab (not posted)
Problem 5. Diabetes Mellitus and Metabolic Monitoring (not posted)
Problem 1. Agranulocytosis secondary to cancer chemotherapy
Problem 2. Diffuse Large B-cell Lymphoma (DLBCL), GCB subtype, Lugano stage III
Problem 3. Hypokalemia and Hypomagnesemia
Problem 4. Thrombocytopenia
This is a 71-year-old woman diagnosed with diffuse large B-cell lymphoma (DLBCL), germinal center B-cell (GCB) subtype, stage III (PET 2024-12-13), undergoing chemotherapy with R-CHOP (C3 administered on 2025-03-19). She has chronic hepatitis B (anti-HBc positive, HBsAg negative) and is on Vemlidy (tenofovir alafenamide) for HBV prophylaxis.
Problem 1. Diffuse Large B-Cell Lymphoma (DLBCL) - Treatment and Response
Problem 2. Hypertension and Cardiovascular Risk
Problem 3. Blood Glucose Variability and Metabolic Control (not posted)
Problem 4. Hematologic Status and Neutropenia Risk
Problem 5. Chronic Pharyngitis and Laryngopharyngeal Reflux (LPR) (below not posted)
Problem 6. Hepatitis B Carrier Status
Final Notes
[lab data]
Body weight
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Key insight / summary
Problem 1. Ampullary adenocarcinoma, adjuvant systemic therapy status and response surveillance
Problem 2. Chemotherapy-related cytopenias: macrocytic anemia, historical neutropenia, fluctuating thrombocytopenia
Problem 3. Electrolyte disturbances (hypokalemia, hypomagnesemia, hypocalcemia) — improved but at risk for recurrence
Problem 4. Splenomegaly on CT with historical thrombocytopenia — possible oxaliplatin-associated sinusoidal injury
Problem 5. Chemotherapy toxicities: nausea, diarrhea, and insomnia — currently grade 0–1 and controlled
Problem 6. Peripheral sensory neuropathy from oxaliplatin — grade 1
Problem 7. Nutrition and weight loss, low BMI — high-risk but recently improving
Problem 8. Psychosocial stress and insomnia — adjustment disorder with anxious mood
Problem 9. Port-A site oozing — no infection signs
Problem 10. Mild hypotension during admission — asymptomatic
Current active/supportive medications of note - Zyprexa Zydis (olanzapine) HS during chemotherapy for antiemesis and sleep (Medication record 2025-09-04). - Emend (aprepitant) D1–3, Aloxi (palonosetron) D1, dexamethasone, diphenhydramine, atropine SC pre-IRI, NS hydration (Chemotherapy orders 2025-09-04). - Anxicam (lorazepam) IV Q12H short course; Metoclopramide IV PRN; Bio-Three probiotics; TAITA No.5 electrolyte solution; Promeran (metoclopramide) PO; Eurodin (estazolam) PRN HS; Simmon ODT (mirtazapine) HS; Through (sennoside) HS; PRN loperamide and Smecta (dioctahedral smectite) for diarrhea (Medication records 2025-03-24, 2025-06-19, 2025-09-04).
Follow-up/monitoring checkpoints - CBC/DC and BMP/Mg/Ca at baseline and nadir each cycle; tumor markers every 4–8 weeks; imaging restage after next cycle block (Labs 2025-09-02; CT 2025-07-15). - Toxicity review at each visit with attention to neuropathy progression, diarrhea control, and cytopenias; consider dose adjustments accordingly.
Subjective
The patient is a 43-year-old woman, recently discharged post first cycle of FOLFIRINOX chemotherapy (2025-03-21 to 2025-03-23) for stage IIIA adenocarcinoma of the ampulla of Vater (post-Whipple operation on 2025-02-12).
Post-FOLFIRINOX (C1D1) Chemotherapy – Adverse Reaction Evaluation
Current medications:
The patient reports:
Objective
Assessment
Plan / Recommendation
This 43-year-old woman is undergoing adjuvant chemotherapy for adenocarcinoma of the ampulla of Vater, staged pT2N1(cM0) IIIA after pancreatoduodenectomy and partial gastrectomy (2025-02-12). She is currently admitted for her fourth chemotherapy cycle (C3D15) of mFOLFIRINOX. Chemotherapy dates include: 2025-03-20 (C1D1), 2025-04-14 (C1D15), 2025-04-30 (C2D1), 2025-05-14 (C2D15), 2025-06-02 (C3D1), and now 2025-06-19 (C3D15). Her treatment course has been complicated by episodes of neutropenia, anemia, mild transaminitis, progressive hypoalbuminemia, and weight loss, necessitating nutritional and psychological support. Her current ECOG performance status is 0.
On 2025-06-19, prior to chemotherapy, labs revealed normothermia and stable vitals. There were mild hypokalemia (K 3.3 mmol/L), hypocalcemia (Ca 1.85 mmol/L), hypoalbuminemia (3.3 g/dL), anemia (Hb 8.9 g/dL), thrombocytopenia (PLT 115 ×10^3/uL), and borderline leukopenia. Parenteral nutrition, hydration, and electrolyte replacement were prescribed.
Problem 1. Adenocarcinoma of ampulla of Vater, pT2N1(cM0) stage IIIA
Problem 2. Chemotherapy-related hematologic toxicity (anemia, thrombocytopenia, leukopenia)
Problem 3. Electrolyte and nutritional disturbances (hypoalbuminemia, hypokalemia, hypocalcemia)
Problem 4. Insomnia and emotional distress
Problem 5. Nephro-hepatic function surveillance (not posted)
[Bedside Visit and Patient Education]
Date & Time of Visit: 2025-03-24 at approximately 13:20
Location: Bedside visit; the patient’s husband was present in the room.
Assessment & Intervention:
I advised the following:
note: The patient has two children - one in second grade and one in fifth grade. The younger one is more mischievous.
[Bedside Visit and Patient Education]
Date & Time of Visit: 2025-03-21 at approximately 11:45
Location: Patient’s room; patient was lying in bed and accompanied by her husband.
Assessment & Intervention:
Observation:
[Patient Evaluation]
The patient is a 43-year-old female with adenocarcinoma of the ampulla of Vater, mixed pancreatobiliary and intestinal type, stage IIIA (pT2N1M0), post-Whipple procedure (2025-02-12). The treatment plan for her is FOLFIRINOX chemotherapy (scheduled on 2025-03-21). Her recovery has been complicated by postoperative intra-abdominal fluid collection requiring pigtail drainage (2025-02-26), as well as significant psychological distress related to her illness.
Problem 1. Adenocarcinoma of Ampulla of Vater, Post-Whipple Procedure
Problem 2. Postoperative Intra-Abdominal Fluid Collection
Problem 3. Postoperative and Chemotherapy-Related Hematological Abnormalities
Problem 4. Psychological Distress and Suicidal Ideation
Problem 5. Postoperative Nutritional Deficiencies and GI Symptoms
[MedRec]
[MedRec]
[Betmiga (mirabegron) tube feeding]
Betmiga 50mg/tab (mirabegron) is not recommended for tube feeding.
Rationale for Betmiga:
Mirabegron (Betmiga) 50mg tablets are formulated as extended-release (ER) tablets. Crushing or breaking extended-release formulations destroys their controlled-release mechanism. This can lead to:
Therefore, for patients requiring tube feeding, Betmiga ER tablets should not be crushed.
Recommendations for Alternatives for Tube Feeding:
Urotrol FC 15mg/tab (propiverine) and Vesicare FC 5mg/tab (solifenacin) are in the same ATC category (G04BD - Drugs for urinary frequency and incontinence) and are typically used for overactive bladder. Both are generally considered suitable for administration via tube feeding:
Important Considerations:
[Xtandi 40mg/tab (Enzalutamide) - tube feeding]
Xtandi (enzalutamide) capsules, as the manufacturer explicitly states that the capsules should not be chewed, dissolved, or opened, and tablets should not be cut, crushed, or chewed.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
2025-06-18 - pembrolizumab 200mg NS 100mL 30min
2025-05-10 ~ 2025-06-02 - Iressa (gefitinib 250mg) 1# QD
This is a 75-year-old woman with left upper lobe (LUL) lung adenocarcinoma, moderately differentiated, stage IVB (cTxN2-3M1c1 per PET 2025-05-21), complicated by multiple brain metastases (MRI 2025-05-10; CT 2025-05-12), EGFR wild-type (2025-05-16), ALK/ROS1 negative (2025-06-02), PD-L1 TPS 90% (2025-06-02). She had previously received palliative radiotherapy to the brain (3000cGy/10 fractions from 2025-05-22 to 2025-06-04) and a short trial of self-paid Iressa (gefitinib 250mg QD from 2025-05-12 to 2025-06-06). She is currently undergoing her first cycle of immunotherapy with Keytruda (pembrolizumab) 200mg (C1 on 2025-06-18). Clinical condition is ECOG PS 4, with persistent left-sided weakness and no current seizures or fever. Labs on 2025-06-18 showed normonatremia (Na 135 mmol/L), borderline hypokalemia (K 3.0 mmol/L), anemia (Hb 8.9 g/dL), preserved renal and liver function.
Problem 1. Metastatic LUL adenocarcinoma (cTxN2-3M1c1, PD-L1 high)
Problem 2. Neurologic impairment from brain metastases
Problem 3. Anemia (Hb <9.0 g/dL)
Problem 4. Electrolyte imbalance (hypokalemia, borderline hyponatremia)
Problem 5. Functional decline and poor performance status (ECOG 4)
[Mild hypokalemia associated with steroid use]
Mild hypokalemia associated with steroid use, particularly glucocorticoids like Compesolon (prednisolone), is due to their mineralocorticoid activity, which can lead to renal potassium wasting. Here’s the step-by-step rationale:
Prednisolone, while primarily a glucocorticoid, still retains some mineralocorticoid effect, especially at moderate to high doses.
This effect promotes renal sodium retention and potassium excretion in the distal nephron (via ENaC activation and Na⁺/K⁺ exchange).
The end result is hypokalemia, especially in patients who are:
In this case, the patient is on prednisolone 10 mg BID (equivalent to 40 mg hydrocortisone per day), which is sufficient to cause mild K⁺ loss over days, especially in a fragile, hyporexic elderly patient.
Supporting reference:
Therefore, the ongoing Const-K (potassium chloride) supplementation is appropriate, and potassium trends should continue to be monitored.
[Tagrisso (osimertinib)]
Use of Tagrisso (osimertinib) in this patient is not appropriate, based on the current molecular profile and guideline-based indications. Here’s a structured analysis:
Summary:
This is a 75-year-old female with:
Commentary on Osimertinib Use
In summary:
Osimertinib is not appropriate for this patient due to lack of EGFR mutation. Treatment with pembrolizumab is guideline-concordant.
[The use of Iressa (gefitinib 250mg QD from 2025-05-10 to 2025-06-02)]
The use of Iressa (gefitinib 250mg QD from 2025-05-10 to 2025-06-02) in this case appears to be a provisional, off-label, and ultimately inappropriate treatment, though contextually understandable as an urgent empirical measure. Here’s the stepwise analysis:
Conclusion
The 2025-05-10 to 2025-06-02 course of Iressa:
[exam finding]
[MedRec]
[Patient Summary]
Demographics: 62-year-old male with no prior known systemic diseases; regular user of Chinese herbal medicine; non-smoker.
Presentation: Presented on 2025-05-16 with:
Diagnosis:
Hospital Course:
Planned Treatment:
Prognosis:
[Subjective]
medication adherence and procedure readiness
[Objective]
recent treatment and monitoring
[Assessment]
medication adherence confirmed; CABG schedule under reconsideration
[Plan / Recommendation]
pharmacist support for safe transition toward surgery or modified plan
[treatment]
Based on the patient data provided, the treatment plan is appropriate and evidence-based for a patient with:
A. Key Insight / Summary
This is a 62-year-old male with new-onset NSTEMI, found to have severe 3-vessel disease with:
Cardiac enzymes (hs-TnI) peaked to 46880.2 pg/mL on 2025-05-17, then trended down to 106.8 pg/mL by 2025-05-26, consistent with recent myocardial injury and stabilization.
Echocardiography (2025-05-19) showed preserved systolic function (LVEF 55%) with trivial MR/TR and no wall motion abnormalities.
He is planned for elective total arterial coronary artery bypass grafting (CABG) on 2025-07-09, after cardiology consultation and shared decision-making, with reasonable surgical risk and preserved function.
B. Problem-Oriented Deliberation
Problem 1. Acute Coronary Syndrome (NSTEMI) and 3-Vessel CAD
Problem 2. Antiplatelet and Secondary Prevention
Problem 3. Electrolyte and Volume Status
Problem 4. Thyroid Function
C. Overall Assessment of Treatment Plan
[Why CABG? Why not balloon angioplasty or stenting (PCI)?]
In this simulated patient, balloon angioplasty or stenting (PCI) was not chosen as definitive treatment because anatomic and clinical factors strongly favor CABG. Here’s a detailed, evidence-based explanation:
A. Key Clinical and Angiographic Findings Against PCI
B. Why PCI is Suboptimal Here
C. Why CABG Is the Better Option
D. Guidelines Support
According to:
“CABG is recommended over PCI in patients with multivessel CAD and a high SYNTAX score (≥23), particularly if complete revascularization is unlikely with PCI.”
E. Summary
Balloon angioplasty or stenting was not performed because:
Therefore, CABG is the more appropriate and guideline-concordant choice in this patient.
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Subjective]
chemotherapy-related adverse effect
communication and follow-up
[Objective]
adverse drug reaction
current medications (2025-06-16 prescribed)
[Assessment]
paclitaxel hypersensitivity reaction
[Plan / Recommendation]
optimize paclitaxel administration
monitoring and coordination
The patient is a 59-year-old male with a diagnosis of moderately differentiated squamous cell carcinoma of the right hilar lung, clinical stage cT4N3M0 (stage IIIC), presenting initially with chronic cough and weight loss. He is receiving concurrent chemoradiotherapy (CCRT) with weekly paclitaxel + cisplatin. Pathology confirmed squamous histology (biopsy 2025-05-15). PD-L1 is negative (TPS 0%), and no EGFR/ALK mutation is present. Imaging (PET 2025-05-19, CT 2025-04-15) confirms bulky right hilar and mediastinal lymphadenopathy with no distant metastases. He has emphysematous COPD and reflux esophagitis. He tolerated 2 cycles of chemotherapy with manageable adverse effects but developed an infusion reaction on 2025-06-11.
Problem 1. Primary Lung Cancer (SqCC, cT4N3M0, stage IIIC)
Problem 2. Chemotherapy-Related Hypersensitivity (Paclitaxel, 2025-06-11)
Problem 3. Anemia
Problem 4. COPD with Emphysema
Problem 5. Nutritional Risk and Cancer Cachexia
Problem 6. Psychosocial and Economic Burden
[anemia] (not posted)
The labs:
→ This pattern is not consistent with iron overload, despite the high ferritin.
Interpretation:
This pattern is most consistent with anemia of chronic inflammation (ACI), sometimes called anemia of chronic disease (ACD).
Why it is not classic iron deficiency anemia:
This patient, however, has elevated ferritin and low transferrin saturation, which is characteristic of inflammatory anemia (like that associated with cancer) — not classic IDA.
Conclusion:
[albumin-bound paclitaxel (nab-paclitaxel)] (not posted)
Albumin-bound paclitaxel (nab-paclitaxel) is included in the NCCN Clinical Practice Guidelines for Non-Small Cell Lung Cancer (NSCLC) as a recommended regimen for squamous cell carcinoma in specific contexts.
Based on the NCCN Guidelines Version 5.2024 and continuing into 2025:
Conclusion:
[exam finding]
[chemotherapy]
This 73-year-old male with metastatic pancreatic adenocarcinoma (T4N2M1, stage IV) complicated by lung, liver, lymph node metastases, and obstructive cholangitis (post-ERBD), presents with acute decompensation characterized by:
The patient is DNR with hospice referral pending. He is managed with IV antibiotics (Tapimycin), transfusions, hyperkalemia rescue (e.g., sodium bicarbonate), and supportive care.
Problem 1. Acute Kidney Injury on CKD stage 3
Problem 2. Electrolyte Imbalances - Severe Hyperkalemia, Hyponatremia
Problem 3. Anemia and Thrombocytopenia
Problem 4. Sepsis and Acute Respiratory Compromise
Problem 5. Advanced Pancreatic Cancer with Metastases
[lab data]
2024-07-16 HBsAg Nonreactive
2024-07-16 HBsAg Value 0.43 S/CO
2024-07-16 Anti-HBs 2.64 mIU/mL
2024-07-16 Anti-HBc Reactive
2024-07-16 Anti-HBc Value 5.82 S/CO
2024-03-29 HBsAg (NM) Negative
2024-03-29 HBsAg Value (NM) 0.458
2024-03-29 Anti-HBc (NM) Positive
2024-03-29 Anti-HBc Value (NM) 0.007
2024-03-29 Anti-HCV (NM) Negative
2024-03-29 Anti-HCV Value (NM) 0.04
[exam finding]
[MedRec]
[consultation] (not completed)
[surgical operation]
[immunochemotherapy]
This is a 46-year-old man with locally advanced adenocarcinoma of the splenic flexure of the colon (pT4bN1bM1a, Stage IVC) with left supraclavicular lymph node, liver, and peritoneal metastases, complicated by recurrent adhesive small bowel obstruction, enterocutaneous fistula, and progressive carcinomatosis. He has undergone multiple laparotomies and bowel bypass procedures, with current chemotherapy based on modified FOLFIRI (Avastin held temporarily). Latest PET on 2025-06-10 revealed progressive liver and peritoneal FDG activity. He currently exhibits stable vital signs, well-controlled pain, and Grade 1 fatigue and diarrhea under chemotherapy. Lab data show mild anemia, normal renal/liver function, and no significant electrolyte disturbance.
Problem 1. Metastatic colon adenocarcinoma (stage IVC, pT4bN1bM1a)
Problem 2. Enterocutaneous fistula and surgical wound complication
Objective
Assessment
Recommendation
Problem 3. Small bowel obstruction status post multiple surgeries
Problem 4. Cancer cachexia and nutritional support
Problem 5. Pain management
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 75-year-old woman with stage IV peritoneal mesothelioma (cT4N2M1, ECOG 3) complicated by liver metastasis, carcinomatosis, and malignant ascites, has received three cycles of immunochemotherapy (Atezolizumab, Bevacizumab, Pemetrexed, Carboplatin) between 2025-03-27 and 2025-05-20 with fair tolerance. She now presents with abdominal distention and lower limb twitching. Despite intermittent febrile episodes and mild lab abnormalities (e.g., normocytic anemia, hypoalbuminemia, mild hyponatremia), her imaging suggests partial disease response with stable to regressing carcinomatosis. Her performance status and lab stability currently support continuation of systemic therapy. Ascites is persistent and symptomatic, with analysis planned.
Problem 1. Peritoneal mesothelioma with liver metastasis, carcinomatosis, and malignant ascites (cT4N2M1, stage IV, ECOG 3)
Problem 2. Normocytic anemia
Problem 3. Recurrent malignant ascites
Problem 4. Dermatologic infection (Carbuncle)
Problem 5. Hyponatremia and electrolyte imbalance (not posted)
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
The patient is a 51-year-old male with stage IVB right upper lobe pulmonary adenocarcinoma (cT4N3M1c2, AJCC 9th ed.) confirmed by liver biopsy on 2024-12-27. He presents with progressive dyspnea since 2025-06-12, now associated with right-sided pleural effusion, leukocytosis, anemia, and new bone metastases. Disease progression is evident radiologically (bone scan 2025-06-13; CXR 2025-06-14) and biochemically (CEA rising, CRP 16.9 mg/dL on 2025-06-12). The patient is currently receiving inpatient care, on empiric antibiotics, symptomatic treatments, and pigtail drainage. ECOG performance status is 2. Treatment with pemetrexed + cisplatin chemotherapy (last cycle 2025-05-09) likely no longer effective.
Problem 1. Progressive metastatic lung adenocarcinoma (pleura, bone, liver)
Problem 2. Right pleural effusion with dyspnea
Problem 3. Bone metastases
Problem 4. Anemia and leukocytosis (not posted)
Problem 5. Hyponatremia and electrolyte imbalance (not posted)
[exam finding]
[MedRec]
[consultation]
This is an 84-year-old woman with left lower lobe lung adenocarcinoma (EGFR L861Q) with brain, liver, bone, and pulmonary metastases (cT4N2bM1c2, stage IVB). She was treated with Giotrif (afatinib) since 2025-05-12 and palliative brain RT from 2025-05-23 to 2025-06-05. She was admitted on 2025-06-13 for worsening general weakness, fatigue, poor appetite, and leukocytosis. The patient also has type 2 diabetes with previously uncontrolled hyperglycemia (max glucose 768 mg/dL on 2025-05-16), chronic hepatitis B on Vemlidy (tenofovir alafenamide), cachexia, prior treated Aspergillus infection, and an extensive list of comorbidities (CHF, COPD, asthma, atrial arrhythmias, CKD risk).
Vital signs are mostly stable without hypoxia, shock, or persistent fever. Active medications include TPN with vitamins/electrolytes, morphine, Sintum (ceftazidime), megestrol, and dexamethasone. Current problems center around cancer progression, infection/inflammation status, functional deterioration, and malnutrition.
Problem 1. Metastatic lung adenocarcinoma (cT4N2bM1c2, EGFR L861Q)
Problem 2. Suspected sepsis without shock
Problem 3. Functional deterioration and cancer-related cachexia
Problem 4. Type 2 diabetes mellitus with prior hyperglycemic crisis
Problem 5. Electrolyte and renal considerations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a 51-year-old man with stage III squamous cell carcinoma (SCC) of the upper third esophagus (cT3NxM0) confirmed by biopsy (2025-04-23) and imaging (CT 2025-04-28, PET 2025-05-06). He is currently undergoing neoadjuvant concurrent chemoradiotherapy (CCRT) with PF4 regimen since 2025-05-27 and radiotherapy since 2025-05-20. He has a jejunostomy for nutrition and port-A for chemotherapy access. Comorbidities include uncontrolled type 2 diabetes mellitus, recent Klebsiella UTI, aspiration pneumonia, and H. pylori-associated gastritis. Vital signs and labs on 2025-06-15 show hemodynamic stability, normothermia, anemia (Hb 9.7), hypoalbuminemia (Alb 3.1), and adequate renal function (Cr 0.63, eGFR 142.7). Currently ECOG 1.
Problem 1. Esophageal squamous cell carcinoma, stage III, cT3NxM0
Problem 2. Hematologic toxicity and anemia during CCRT
Problem 3. Nutritional status and cachexia
Problem 4. Infection risk: recent Klebsiella UTI and aspiration pneumonia (not posted)
Problem 5. Type 2 diabetes mellitus, poorly controlled (historically) (not posted)
[lab data]
2025-05-14 HBV DNA-PCR (quan) <10 IU/mL
2025-05-08 Anti-HBc Reactive
2025-05-08 Anti-HBc Value 5.67 S/CO
2025-05-08 Anti-HBs 1.01 mIU/mL
2025-05-08 HBsAg Reactive
2025-05-08 HBsAg Value 3.95 S/CO
2025-05-08 Anti-HCV Nonreactive
2025-05-08 Anti-HCV Value 0.13 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This 59-year-old male with squamous cell carcinoma of the upper third of the esophagus (cT2N2M0, Stage III), status post feeding jejunostomy and Port-A insertion on 2025-05-07, is undergoing definitive concurrent chemoradiotherapy (CCRT) with PF regimen and radiation therapy to 50.4 Gy/28 fractions (initiated 2025-05-14). As of 2025-06-13, he is hospitalized for Cycle 2 of chemotherapy (cisplatin + fluorouracil). Current labs reveal preserved renal and hepatic function, microcytic anemia with anisocytosis, neutrophil-predominant leukocytosis, and hyperuricemia. Vital signs are stable, though mild tachycardia was noted on 2025-06-12. No acute complications are reported.
Problem 1. Locally advanced esophageal squamous cell carcinoma (cT2N2M0, Stage III)
Problem 2. Anemia with microcytosis and elevated RDW (not posted)
Problem 3. Renal function and cisplatin safety (not posted)
Problem 4. Hyperuricemia and gout prophylaxis
Problem 5. Cardiopulmonary function and performance status
[exam findings]
[MedRec]
2025-07-22 SOAP Chest Medicine Yang MeiZhen
2025-07-18 SOAP Metabolism and Endocrinology Liao YuHuang
2025-07-18 SOAP Gastroenterology Zhao YouCheng
2025-07-09 ~ 2025-07-14 POMR Hemato-Oncology Xia HeXiong
2025-06-25 SOAP Psychosomatic Medicine Li JiaFu
2025-06-25 SOAP Ophthalmology Xie XiuHui
2025-06-11 ~ 2025-06-15 POMR Hemato-Oncology Xia HeXiong
2024-09-02 ~ 2024-09-06 POMR Colorectal Surgery Chen ZhuangWei
[consultation]
[surgical operation]
[chemotherapy]
[Psychiatric Medication Review]
The patient has been long-term refilling a repeat prescription from the Psychiatry department for Sinmaron Orally Disintegrating (mirtazapine 30mg) 2 tablets nightly (QN). It is recommended that this medication not be re-ordered upon discharge.
The patient is a 57-year-old male with stage IVB adenocarcinoma of the low rectum (cT3N2bM1b), complicated by liver and bone metastases. Disease has progressed after initial response to total neoadjuvant therapy and first-line mFOLFOX ± Bevacizumab. Current treatment involves second-line chemotherapy with Bevacizumab plus FOLFIRI since 2025-07-10. Tumor markers (CEA, CA19-9) are rising (CEA 16.04 ng/mL on 2025-08-21 from 8.51 ng/mL on 2025-07-22), suggesting continued disease activity. Patient has microcytic anemia with high RBC count, likely related to underlying thalassemia. Overall hepatic and renal functions remain preserved. No active serious chemotherapy-related adverse effects documented recently.
Problem 1. Metastatic colorectal cancer, liver and bone metastasis
Problem 2. Chronic microcytic anemia with high RBC count (below not posted)
Problem 3. Glycemic fluctuation in type 2 diabetes
Problem 4. Hepatic and renal function preservation
Problem 5. Constitutional and performance status
The patient is a 57-year-old male with metastatic low rectal adenocarcinoma (cT3N2bM1b, stage IVb) with liver and bone involvement, currently receiving mFOLFOX6 + bevacizumab chemotherapy since 2024-07-29. As of 2025-06-12, his overall condition is stable with ECOG PS 1. Laboratory results show mild but stable microcytic anemia, good renal and hepatic function, and no signs of acute infection or inflammation. Imaging (CT 2025-03-01) suggests stable metastases in the liver and bone. He received his most recent chemotherapy on 2025-05-05, and denosumab was administered on 2025-06-12 for bone metastasis prophylaxis. His blood pressure is stable, diabetes appears controlled, and there is ongoing monitoring and supportive care for his multi-morbidity status.
Problem 0. Metastatic rectal adenocarcinoma (liver and bone) (old version, not posted)
Problem 1. Metastatic rectal adenocarcinoma with liver and bone metastases (cT3N2bM1b, stage IVb, RAS/BRAF wild-type, left-sided)
Problem 2. Skeletal metastasis and SRE (skeletal-related event) prevention
Problem 3. Microcytic anemia
Problem 4. Electrolyte imbalance (Hyponatremia) (not posted)
Problem 5. Type 2 diabetes mellitus (on insulin)
Problem 6. GERD and GI symptoms
Problem 7. Psychosocial and psychiatric vulnerability
[Left-sided colorectal cancers] (not posted)
“Left-sided” colorectal cancers (those originating from the splenic flexure, descending colon, sigmoid colon, and rectum) are clinically and molecularly distinct from “right-sided” cancers (cecum, ascending colon, and proximal transverse colon). This distinction matters particularly in metastatic disease, because it directly influences treatment selection and prognosis, especially regarding anti-EGFR therapy.
Key Differences: Left-sided vs Right-sided Colorectal Cancer
Conclusion:
Since the last review on 2025-01-13, the patient has continued bevacizumab + FOLFOX chemotherapy with cycles administered on 2025-01-23 and 2025-02-27. Laboratory trends indicate stable renal and liver function, mild anemia, and normal inflammatory markers, with no immediate concerns of infection or worsening organ function. However, tumor progression risk remains, necessitating ongoing monitoring and treatment reassessment.
Problem 1. Metastatic Rectal Cancer
Problem 2. Bone Metastases and Skeletal Health
Problem 3. Hematologic Trends and Chemotherapy Tolerance
Problem 4. Renal Function and Electrolyte Balance
Problem 5. Inflammatory and Infection Markers
Summary of Key Changes Since 2025-01-13
Immediate Action Plan
The patient is a 56-year-old male with advanced rectal adenocarcinoma (initially stage IIIC, now progressed to stage IVb with liver and bone metastases) and multiple comorbidities, including type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), alcoholic liver disease, and mood disorder. Over the course of treatment, he has undergone neoadjuvant therapy, multiple cycles of FOLFOX with Avastin (bevacizumab) added since 2024-10-30.
Problem 1. Metastatic Rectal Cancer
Problem 2. Hepatic Function
Problem 3. Bone Metastases
Problem 4. Hematological Concerns
Problem 5. Electrolyte and Renal Concerns
Problem 6. Psychosocial and Functional Status
[Targeted Therapy Options]
Overall Recommendations:
[Improved, but Elevated HbA1c: Continued Monitoring Needed]
For this patient with mCRC, the 2024-07-29 RAS/BRAF mutation test results showing no variants in the KRAS/NRAS (ALL-RAS wild-type) and BRAF wild-type mean that the patient is a candidate for EGFR inhibitor therapy (such as cetuximab or panitumumab).
The patient’s HbA1c level has improved but remains higher than the reference range. His current blood glucose readings are also elevated but are considered acceptable. There are no drug-related issues identified.
[exam finding]
2025-06-09 Peripheral Vascular Test - Artery, lower limbs
2025-06-06 Pathology - colorectal polyp
2025-06-06 Pathology - stomach biopsy
2025-06-05 Esophagogastroduodenoscopy, EGD
2025-06-05 Colonoscopy
2025-06-05 Sonography - abdomen
2025-06-03 Pathology - liver biopsy needle/wedge
2025-05-31 CT - abdomen
2025-05-31 ECG
2025-05-31 KUB
2025-05-31 CXR
2025-02-11 Esophagogastroduodenoscopy, EGD
2024-10-04 Esophagogastroduodenoscopy, EGD
2024-10-02 KUB
2024-08-09 Sonography - nephrology
2024-08-09 2D transthoracic echocardiography
2024-08-08 CXR
2024-08-08 05:49 ECG
2024-08-08 CT - abdomen
2024-08-08 CT - brain
2024-08-08 00:06 ECG
2024-07-18 MRA - brain
2024-07-17 CT - chest
[MedRec] (not completed)
[consultation] (not completed)
[exam finding]
[MedRec]
[exam findings]
[MedRec]
2025-06-02 ~ 2025-06-04 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-05-28 SOAP Ophthalmology Shen PeiYu
2025-03-31 ~ 2025-05-05 POMR Orthopedics Li YiCheng
2025-01-06 SOAP General and Gastroenterological Surgery Zhang YaoRen
2025-01-06 SOAP Metabolism and Endocrinology Qiu QuanTai
2024-10-30 ~ 2024-11-13 POMR Orthopedics Luo Jie
2023-01-15 ~ 2023-01-18 POMR Nephrology Guo KeLin
2022-08-12 ~ 2022-08-20 POMR Infectious Disease Qiu ShengKang
2022-05-30 ~ 2022-06-03 POMR Infectious Disease Wu JunSheng
2021-10-12 ~ 2021-10-14 POMR Hemato-Oncology Zhang ShouYi
2020-09-24 ~ 2020-09-30 POMR General and Gastroenterological Surgery Zhang YaoRen
2020-03-02 ~ 2020-03-04 POMR General and Gastroenterological Surgery Zhang YaoRen
2020-02-06 ~ 2020-02-08 POMR General and Gastroenterological Surgery Zhang YaoRen
2019-08-01 ~ 2019-08-04 POMR General and Gastroenterological Surgery Zhang YaoRen
[immunochemotherapy]
[Subjective]
medication administration and caregiver education
cancer status and supportive medication history
[Objective]
current active medications
laboratory findings on 2025-06-11
[Assessment]
drug-food interaction and administration timing
Enhertu-related adverse event monitoring
polypharmacy considerations
[Plan / Recommendation]
optimize antiviral and fasting medication schedule
Enhertu safety monitoring
review GI protective strategy
evaluate CNS and sedation risks
reassess polypharmacy and therapeutic duplication
follow-up
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
2025-09-15 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (infusor) (Erbitux + FOLFIRI. Irino 75% for DBI 1.66)
2025-08-19 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (infusor) (Erbitux + FOLFIRI)
2025-08-05 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (infusor) (Erbitux + FOLFIRI)
2025-07-22 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (infusor) (Erbitux + FOLFIRI)
2025-07-08 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (infusor) (Erbitux + FOLFIRI)
2025-06-25 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 120mg/m2 220mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (infusor) (Erbitux + FOLFIRI)
2025-06-09 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 120mg/m2 220mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 2hr + fluorouracil 2000mg/m2 3800mg NS 500mL 46hr (Erbitux + FOLFIRI)
2025-05-22 - cetuximab 500mg/m2 1000mg 2hr
2025-05-08 - cetuximab 500mg/m2 1000mg 2hr
2025-04-24 - cetuximab 500mg/m2 1000mg 2hr
2025-04-10 - cetuximab 500mg/m2 1000mg 2hr
2025-03-27 - cetuximab 500mg/m2 1000mg 2hr
2025-03-13 - cetuximab 500mg/m2 1000mg 2hr
2025-03-13 ~ 2025-05-XX - Tafinlar (dabrafenib mesylate 75mg) 2# BIDAC (self-paid)
2025-02-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4700mg NS 170mL 48hr (infusor)
2025-02-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-01-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 170mL 48hr (infusor) (Avastin not enough)
2025-01-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 170mL 48hr (infusor) (Avastin not enough)
2024-12-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 170mL 48hr (infusor) (Avastin not enough)
2024-12-06 - bevacizumab 5mg/kg 397mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 778mg NS 250mL 2hr + fluorouracil 2800mg/m2 5446mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-11-21 - bevacizumab 5mg/kg 358mg NS 100mL 90min + irinotecan 180mg/m2 315mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4910mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-11-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 264mg D5W 250mL 90min + leucovorin 400mg/m2 587mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-10-11 - bevacizumab 5mg/kg 275mg NS 100mL 90min + irinotecan 180mg/m2 244mg D5W 250mL 90min + leucovorin 400mg/m2 543mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-09-20 - bevacizumab 5mg/kg 278mg NS 100mL 90min + irinotecan 180mg/m2 244mg D5W 250mL 90min + leucovorin 400mg/m2 543mg NS 250mL 2hr + fluorouracil 2800mg/m2 3808mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-08-30 - bevacizumab 5mg/kg 277mg NS 100mL 90min + irinotecan 180mg/m2 244mg D5W 250mL 90min + leucovorin 400mg/m2 543mg NS 250mL 2hr + fluorouracil 2800mg/m2 3806mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-08-09 - bevacizumab 5mg/kg 273mg NS 100mL 90min + irinotecan 180mg/m2 243mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3780mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-07-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-06-21 - bevacizumab 5mg/kg 391mg NS 100mL 90min + irinotecan 180mg/m2 346mg D5W 250mL 90min + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5395mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-06-07 - bevacizumab 5mg/kg 388mg NS 100mL 90min + irinotecan 180mg/m2 346mg D5W 250mL 90min + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5395mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-05-24 - bevacizumab 5mg/kg 385mg NS 100mL 90min + irinotecan 180mg/m2 345mg D5W 250mL 90min + leucovorin 400mg/m2 765mg NS 250mL 2hr + fluorouracil 2800mg/m2 5359mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-05-10 - bevacizumab 5mg/kg 385mg NS 100mL 90min + irinotecan 180mg/m2 345mg D5W 250mL 90min + leucovorin 400mg/m2 765mg NS 250mL 2hr + fluorouracil 2800mg/m2 5359mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-04-26 - (Avastin + FOLFIRI)
2024-04-11 - (Avastin + FOLFIRI)
2024-03-21 - (Avastin + FOLFIRI)
2024-03-01 - (Avastin + FOLFIRI)
2024-02-15 - (FOLFIRI)
2024-01-24 - (FOLFIRI)
He has BRAF V600E–mutated, KRAS/NRAS wild-type metastatic sigmoid colon adenocarcinoma, post laparoscopic sigmoidectomy (pathology pT3N1bM1b; LVI/PNI present) (pathology 2023-12-14; molecular 2023-12-26). He received Tafinlar (dabrafenib mesylate) 75 mg, 2 capsules BIDAC from 2025-03-13 until mid-May, together with Erbitux (cetuximab) Q2W (chemo 2025-03-13 to 2025-05-22). He then transitioned to Erbitux (cetuximab) + FOLFIRI beginning 2025-06-09 and remains on this regimen with dose-adjusted irinotecan per bilirubin (chemo 2025-06-09 to 2025-09-15; labs 2025-09-15). Imaging shows regression of mesenteric/peritoneal disease and of a left lower lung subpleural nodule with persistent liver metastases (CT 2025-08-26). Liver tests remain chronically abnormal but bilirubin improved vs June (labs 2025-06-09; labs 2025-09-15). Admission hypokalemia/hypomagnesemia corrected by 2025-09-16; ECOG PS is 1.
Problem 1. Metastatic sigmoid colon adenocarcinoma (BRAF V600E), progressed on BRAFi + Anti-EGFR, now on Erbitux + FOLFIRI
Problem 2. Hepatic dysfunction under metastatic burden and cytotoxic/targeted therapy
Problem 3. Electrolyte disturbances (hypomagnesemia with secondary hypokalemia) related to Anti-EGFR therapy and GI losses
Problem 4. Hematological status: mild chemotherapy-associated anemia, platelets and WBC adequate
Problem 5. Type 2 diabetes mellitus, improved glycemic control with potential steroid-related excursions
Problem 6. Hypertension and dyslipidemia, generally controlled; hypertriglyceridemia noted
Problem 7. Constipation risk and GI symptom control during chemotherapy
Problem 8. Resolved hepatitis B with antiviral prophylaxis
Problem 9. Possible prostate lesion on imaging
Problem 10. Vascular access and infection prophylaxis
Problem 11. Nutrition, performance status, and supportive medications
This is a 62-year-old male with advanced sigmoid colon adenocarcinoma (cT4aN2bM1b, pT3N1bM1b, stage IVb) post-laparoscopic sigmoidectomy (2023-12-14), with progressive liver and nodal metastases despite multiple lines of palliative chemotherapy. He recently transitioned to Erbitux + FOLFIRI (first dose on 2025-06-09) after disease progression under prior Avastin + FOLFIRINOX. Tumor burden is increasing (CEA 1866→2329 ng/mL from 2025-05-22 to 2025-06-05; CT 2025-05-29 showed liver nodules up to 3.0 cm, new 0.9 cm lesion at LLL). Concurrent chronic conditions include type 2 diabetes (HbA1c 7.5–7.7%) and resolved HBV (Anti-HBc+), under antiviral prophylaxis with Baraclude (entecavir). He presents with abdominal distension and constipation; labs show transaminitis, cholestasis, and mild hypoMg. Clinical status is ECOG PS 1, afebrile, hemodynamically stable.
Problem 1. Progressive sigmoid colon adenocarcinoma with liver and nodal metastases
Problem 2. Hepatic dysfunction (transaminitis and cholestasis)
Problem 3. Type 2 diabetes mellitus
Problem 4. Electrolyte disturbances: hypokalemia and hypomagnesemia
Problem 5. Constipation and abdominal distension
[monitoring diarrhea occurrence after chemotherapy dosage adjustment]
Palliative chemotherapy with FOLFIRI was started on 2024-01-24, and Avastin was added on 2024-02-15. This regimen has been in use for approximately six months. Although both irinotecan and fluorouracil can cause diarrhea, the patient has tolerated them well in the past. This raises the question of whether the patient’s condition or physiology has changed, warranting further investigation.
The most recent administration of Avastin + FOLFIRI was on 2024-07-19, with the dosage adjusted to 80% of the previous amount. This is a reasonable measure, and further observation is needed to determine if diarrhea still occurs.
[exam finding]
[MedRec]
[surgical operation]
[lab data]
2025-05-22 HBsAg Nonreactive
2025-05-22 HBsAg Value 0.34 S/CO
2025-05-22 Anti-HBs 2.59 mIU/mL
2025-05-22 Anti-HBc Nonreactive
2025-05-22 Anti-HBc Value 0.23 S/CO
2025-05-22 Anti-HCV Nonreactive
2025-05-22 Anti-HCV Value 0.12 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a postoperative patient with advanced right buccal squamous cell carcinoma (pT4aN3b, AJCC IVB per pathology 2025-05-02) who underwent extensive surgery including wide excision, right neck dissection, marginal mandibulectomy, partial maxillectomy, and tracheostomy. Imaging from 2025-05-23 shows persistent cardiomegaly and bilateral pulmonary interstitial changes. Blood tests from 2025-05 to 2025-06 reveal ongoing anemia, intermittent hypokalemia, and improving nutritional markers (albumin trending up). Inflammatory markers (CRP) have gradually improved. The patient is on multiple oral medications including antihypertensives, antidiabetics, antiplatelets, and pain/antispasmodic agents. Blood pressure remains elevated despite treatment. Glucose levels are suboptimally controlled with recent values of 135–147 mg/dL. Audiometry (2025-05-20) shows asymmetric mixed hearing loss, more severe on the right.
Problem 1. Advanced Buccal Cancer (pT4aN3b, postoperative)
Problem 2. Normocytic Anemia with Iron Deficiency
Problem 3. Chronic Inflammation (elevated CRP)
Problem 4. Hypokalemia (intermittent, moderate)
Problem 5. Suboptimal Blood Pressure Control
Problem 6. Suboptimally Controlled Type 2 Diabetes Mellitus
Problem 7. Hearing Loss (asymmetric)
[lab data]
2025-04-28 HBV-DNA-PCR Target Not Detected IU/mL
2025-04-01 HBsAg (NM) Negative
2025-04-01 HBsAg Value (NM) 0.382
2025-04-01 Anti-HBc (NM) Positive
2025-04-01 Anti-HBc Value (NM) 0.009
2025-04-01 Anti-HBs (NM) Negative
2025-04-01 Anti-HBs value (NM) <2.0 mIU/mL
2025-04-01 Anti-HCV (NM) Negative
2025-04-01 Anti-HCV Value (NM) 0.033
[exam finding]
[MedRec]
[surigcal operation]
[radiotherapy]
[chemotherapy]
This is a 71-year-old male with no significant comorbidities, recently diagnosed with stage IIIB low rectal adenocarcinoma (cT3N2aM0), EGFR(+), MMR-proficient (MLH1/PMS2/MSH2/MSH6 positive), complicated by obstruction, status post transverse loop colostomy on 2025-04-10. He is undergoing total neoadjuvant therapy (TNT), including chemoradiotherapy with bolus 5-FU and pelvic RT. As of 2025-06-09, he has completed two cycles of CCRT and is clinically stable, with preserved organ function, mild anemia, and no major toxicities. Concurrent HBV infection (anti-HBc positive, HBsAg negative, undetectable HBV DNA) is under prophylaxis with Vemlidy (tenofovir alafenamide). Vital signs remain stable, and no febrile or hemodynamic complications have emerged.
Problem 1. Rectal adenocarcinoma, stage IIIB (cT3N2aM0), undergoing CCRT
Problem 2. Chronic hepatitis B (anti-HBc+), on antiviral prophylaxis
Problem 3. Anemia
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Broen-C Enteric-coated Tablet (Bromelain 20,000 units & L-Cysteine 20 mg) for Tube Feeding]
Key Points
Summary:
This 64-year-old woman with esophageal squamous cell carcinoma (middle third, cT3N3M0, stage IVA) and synchronous hypopharyngeal squamous cell carcinoma (left pyriform sinus/posterior wall, cT2N0M0, stage II) has completed 20 fractions of concurrent chemoradiotherapy (CCRT) with cisplatin + fluorouracil (2025-04-22 to 2025-04-25, 2025-05-23 to 2025-05-26), totaling 4000cGy to the hypopharynx and 3600cGy to the esophagus. She is experiencing treatment-related mucositis, esophagitis, and hematologic suppression, yet maintains a stable ECOG 1 with minimal weight loss and no systemic disease progression to date (MRI 2025-04-12, PET 2025-03-26, Bone Scan 2025-04-14). HBV remains under control on Vemlidy (tenofovir alafenamide) prophylaxis.
Problem 1. Esophageal squamous cell carcinoma (cT3N3M0, stage IVA)
Problem 2. Hypopharyngeal squamous cell carcinoma (cT2N0M0, stage II)
Problem 3. Bone marrow suppression (anemia, thrombocytopenia, leukopenia)
Problem 4. Nutritional compromise and weight loss risk
Problem 5. Chronic hepatitis B carrier under prophylaxis
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Patient Evaluation
Problem 1. Large cell neuroendocrine carcinoma with progression
Problem 2. Suspected Rhabdomyolysis
In summary, while the current CK levels do not confirm rhabdomyolysis, the clinical picture and associated laboratory findings raise concern for early or mild muscle injury potentially related to lurbinectedin therapy. Close monitoring and further diagnostic evaluation are warranted to prevent progression and manage potential complications.3
Problem 3. Urine retention
Problem 4. Diarrhea
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[high HBV DNA PCR level]
The high HBV DNA PCR level of 999,000 IU/mL on 2025-03-22 in this patient strongly suggests active HBV replication, which may represent HBV reactivation, especially in the context of cancer and immunosuppressive therapy.
Interpretation:
Medication Consideration:
Summary:
[exam finding]
2025-05-16 Pap’s Smear
2025-05-02 CT
2025-03-17 KUB
2025-03-13 Sonography - gynecology
2025-03-12 Sonography - nephrology
2025-03-12 2D transthoracic echocardiography
2025-03-10 ECG
2025-02-19 ECG
2025-01-21 Uroflowmetry
2025-01-21 Bladder Sonography
2025-01-20 SONO - abdomen
2025-01-06, 2024-12-30, -12-09 CXR
2024-12-17 CT - chest
2024-11-28 ENT Hearing Test
2024-11-13 SONO - urology
2024-10-29 Pathology - stomach biopsy
2024-10-29 Esophagogastroduodenoscopy, EGD
2024-10-24 SONO - nephrology
2024-09-09, -08-21 CXR
2024-09-09 Pathology - lung transbronchial biopsy
2024-08-29 PET
2024-08-21 CT - abdomen
2024-08-12 Pap’s
2024-05-23 MRI - pelvis
2024-05-08 SONO - urology
2024-01-22 SONO - urology
2024-01-13 ECG
2024-01-13 CT - abdomen
2023-12-14 CT - abdomen
2023-11-13 SONO - urology
2023-11-13 Bladder Sonography
2023-11-13 Uroflowmetry
2023-07-29 SONO - urology
2023-07-29 Bladder Sonography
2023-07-29 Uroflowmetry
2023-06-29 Anoscopy
….-..-..
2023-03-28 Pathology - uterus (with or without SO) neoplastic
2023-03-27 Pathology - colorectal polyp
2023-03-27 Pathology - stomach biopsy
2023-03-24 CT - chest
2023-03-20 MRI - pelvis
2023-03-17 Gynecologic ultrasonography
2023-03-10 Pathology - vaginal biopsy
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-06-05 - paclitaxel 145mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 2hr
2025-05-03 - paclitaxel 145mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 2hr
2025-04-08 - paclitaxel 145mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 2hr
2025-03-05 - paclitaxel 145mg/m2 200mg NS 500mL 3hr + carboplatin AUC 5 250mg NS 250mL 2hr
2025-01-17 - paclitaxel 120mg/m2 180mg NS 500mL 3hr + carboplatin AUC 5 250mg NS 250mL 2hr (paclitaxel + carboplatin. renal dose)
2024-12-19 - paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 350mg NS 250mL 2hr (paclitaxel + carboplatin)
2024-12-16 - Keytruda (pembrolizumab) 200mg NS 190mL 30min
2024-11-01 - Keytruda (pembrolizumab) 200mg NS 190mL 30min
2024-09-24 - Keytruda (pembrolizumab) 200mg NS 190mL 30min
2024-10-08 - Lenvima (lenvatinib 10mg) 1# QD 20D (OPD prescription)
2024-09-24 - Lenvima (lenvatinib 10mg) 1# QD 7D (Discharge prescription)
2023-12-13 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-11-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-10-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-09-01 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-08-11 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-07-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-06-20 - carboplatin AUC 2 150mg D5W 2hr (weekly CDDP changed to carboplatin, CCRT)
2023-06-13 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-06-06 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-05-30 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-05-22 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-05-02 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
This 70-year-old woman with FIGO stage IIIC endometrial carcinosarcoma is undergoing her 6th cycle of self-paid paclitaxel + carboplatin chemotherapy (initiated 2024-12-19) following progression under pembrolizumab + lenvatinib. Disease is metastatic (lung confirmed, 2024-09-09 biopsy), with persistent complications including stage 4 chronic kidney disease (CKD), normocytic macrocytic anemia, and intermittent UTI with prior Enterococcus faecalis bacteremia (2025-02-19). She remains ECOG 1, afebrile, and hemodynamically stable (BP range 105–134/58–66 mmHg, SpO2 ≥95%) during current admission (2025-06-04), but shows progressive marrow suppression.
Problem 1. Chronic Kidney Disease (Stage 4)
Problem 2. Normocytic, Macrocytic Anemia (Treatment-Related)
Problem 3. Leukopenia and Neutropenia
Problem 4. Liver Enzyme Elevation (Mild)
Problem 5. Hypothyroidism
[Recommendation Regarding Teicoplanin Dosing Adjustment]
Given the patient’s CrCl of 22 mL/min (2025-02-19) and an eGFR of 25.88 mL/min/1.73m², renal impairment is evident. Current dosing of Targocid (teicoplanin) 400 mg IVD QD does not align with Sanford Guide recommendations for CrCl < 30 mL/min, which suggest a maintenance dose of 6–12 mg/kg Q72H.
Recommended Adjustment:
[Key Summary]
This is a 69-year-old woman with a history of metastatic endometrial carcinosarcoma diagnosed in 2023. She underwent staging surgery, adjuvant concurrent chemoradiotherapy (CCRT) with weekly Cisplatin, subsequent chemotherapy (paclitaxel + carboplatin), and immunotherapy (pembrolizumab + lenvatinib).
Complications include bilateral hydronephrosis requiring serial DJ stent placement, progressive renal impairment, anemia, gastrointestinal ulcers, and lung metastasis. She is currently on chemotherapy with renal-adjusted doses of Paclitaxel + Carboplatin.
[Problem Comments]
Problem 1. Renal Impairment
Problem 2. Pulmonary Metastasis
Problem 3. Hematological Abnormalities (not posted)
Problem 4. Gastrointestinal Ulcers (not posted)
Problem 5. Hypertension and Headache (Lenvatinib-Related Toxicity)
The leukopenia observed on 2023-08-24 (WBC 1.5K/uL) was likely a result of the paclitaxel and carboplatin administered on 2023-08-11. Following a 3-day course of G-CSF from 2023-08-24 to 2023-08-26, no further instances of leukopenia have been observed.
A new cycle of the treatment regimen was initiated on 2023-09-01, and prophylactic G-CSF is scheduled for 2023-09-06, 2023-09-07, and 2023-09-08.
2023-08-31 WBC 3.20 x10^3/uL
2023-08-24 WBC 1.50 x10^3/uL
2023-08-08 WBC 5.12 x10^3/uL
2023-07-25 WBC 3.29 x10^3/uL
2023-07-17 WBC 5.76 x10^3/uL
2023-07-12 WBC 4.41 x10^3/uL
2023-07-03 WBC 1.64 x10^3/uL
2023-06-28 WBC 1.69 x10^3/uL
2023-06-19 WBC 2.08 x10^3/uL
2023-06-12 WBC 2.72 x10^3/uL
2023-06-05 WBC 4.78 x10^3/uL
2023-05-30 WBC 3.99 x10^3/uL
2023-05-22 WBC 4.35 x10^3/uL
2023-05-15 WBC 4.67 x10^3/uL
2023-05-12 WBC 4.78 x10^3/uL
2023-05-09 WBC 8.17 x10^3/uL
2023-05-09 WBC 13.14 x10^3/uL
2023-04-19 WBC 5.07 x10^3/uL
2023-04-03 WBC 5.23 x10^3/uL
2023-03-28 WBC 13.97 x10^3/uL
2023-03-23 WBC 7.35 x10^3/uL
2023-03-03 WBC 5.22 x10^3/uL
The Eltroxin (levothyroxine) prescribed by our endocrinologist on 2023-08-01 is currently listed in the active medications without any reconciliation discrepancies identified.
Our endocrinologist wrote a repeat prescription for Eltroxin (levothyroxine) on 2023-08-01 and the drug is included in the formulary with no reconciliation issue identified.
[reconciliation]
The patient was seen by our urologist on 2023-07-12 who prescribed Cero (cefaclor 250mg) 2# TID and Celebrex (celecoxib 200mg) 1# QD for a period of 7 days to treat suspected UTI infection or catheter-related discomfort. These medications are not currently on the active medication list, so it’s advisable to confirm resolution of these symptoms.
[exam finding]
[MedRec]
This is a patient (74M) with a history of type 2 diabetes mellitus (T2DM), Parkinson’s disease, and prior benign prostatic hyperplasia (BPH) status post laser TURP (2017-08-04). On 2025-05-23, he developed watery diarrhea and was admitted for evaluation. Excisional biopsy of a left axillary mass on 2025-05-13 revealed lymph node metastatic carcinoma with IHC suggestive of non-hepatocytic, non-RCC, non-pulmonary, non-prostatic, non-colorectal origin. Abdominal CT (2025-06-02) revealed no recurrence in post-LAR colon site, and a stable S4 hepatic hemangioma. Labs show preserved organ function. HbA1c remains mildly elevated (7.5% on 2025-05-23). The patient remains afebrile, hemodynamically stable, with normal inflammatory markers and electrolytes.
Problem 1. Metastatic Carcinoma of Unknown Primary (CUP)
Problem 2. Type 2 Diabetes Mellitus
Problem 3. Gastrointestinal Symptom: Watery Diarrhea (not posted)
Problem 4. Chronic Kidney Disease and Volume Status (not posted)
[lab data]
2025-06-03 HBsAg (NM) Negative
2025-06-03 HBsAg Value (NM) 0.385
2025-06-03 Anti-Hbe (NM) Negative
2025-06-03 Anti-Hbe Value (NM) 1.130
2025-06-03 Anti-HBs (NM) Positive
2025-06-03 Anti-HBs value (NM) 53.300 mIU/mL
2025-06-03 Anti-HBc (NM) Positive
2025-06-03 Anti-HBc Value (NM) 0.009
2025-06-03 Anti-HCV (NM) Negative
2025-06-03 Anti-HCV Value (NM) 0.034
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Subjective]
FOLFOX-related side effect education
Hepatitis B history and antiviral consideration
[Objective]
FOLFOX chemotherapy course 1 administered 2025-05-29
HBV serology (2025-06-03)
Renal function adequate (2025-05-29)
[Assessment]
FOLFOX-related adverse effect monitoring
Chronic hepatitis B (resolved) with risk of chemotherapy-induced reactivation
[Plan / Recommendation]
Supportive care for FOLFOX
HBV reactivation risk mitigation
recommend HBV DNA quantitative testing at next clinic visit if not yet done
if viral load is detectable or patient becomes immunosuppressed, suggest initiating antiviral prophylaxis
document HBV risk and flag for doctor’s review before cycle 2 (scheduled 2025-06-12)
Patient evaluation
Problem 1. Stage IIIC colon adenocarcinoma, post hemicolectomy, adjuvant mFOLFOX6 initiated
Problem 2. Possible early metastatic or indeterminate lesions (lung, renal nodules on CT)
Problem 3. Postoperative renal function trend
Problem 4. Cardiovascular history (CAD with stent, HTN, no angina)
Problem 5. Hepatitis B serology and reactivation risk
[lab data]
2025-05-06 Anti-HBc Reactive
2025-05-06 Anti-HBc-Value 6.17 S/CO
2025-05-06 Anti-HBs 1.20 mIU/mL
2025-05-06 HBsAg Reactive
2025-05-06 HBsAg Value 3844.50 S/CO
2025-05-06 Anti-HCV Nonreactive
2025-05-06 Anti-HCV Value 0.09 S/CO
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Subjective]
tube feeding tolerance and post-treatment condition
discharge prescription and symptom management
[Objective]
antiviral prophylaxis and hepatic monitoring
tolerance to enteral feeding and supportive care
chemotherapy and recent adverse effect profile
[Assessment]
HBV reactivation prophylaxis
nutrition and drug delivery via jejunostomy
adverse drug reaction and symptom burden
[Plan / Recommendation]
antiviral monitoring
nutrition and administration support
symptom monitoring and supportive care
clinical pharmacist follow-up
This is a 60-year-old man diagnosed with stage III (cT3N2M0, AJCC 8th) moderately differentiated squamous cell carcinoma of the lower third of the esophagus (biopsy 2025-04-30; PET 2025-05-07; EUS 2025-05-08). He presented with progressive dysphagia and weight loss since NSAID use for shoulder trauma. The tumor obstructed the lumen and necessitated feeding jejunostomy and Port-A placement (2025-05-14). He underwent concurrent chemoradiotherapy with cisplatin + 5-FU (PF4; 2025-05-20 to 2025-05-23) and RT (2700 cGy/15 fractions to 2025-06-02), with generally well-tolerated effects. He has chronic hepatitis B (HBsAg 3844.5 S/CO, Anti-HBc reactive on 2025-05-06), managed with Vemlidy (tenofovir alafenamide). His recent labs show stable renal and hepatic function, mild normocytic anemia (HGB 10.8 g/dL on 2025-05-26), and transient leukopenia post-chemotherapy (WBC 3.21 x10^3/uL on 2025-05-26).
Problem 1. Esophageal squamous cell carcinoma, stage III (cT3N2M0)
Problem 2. Chronic hepatitis B with high HBsAg titer
Problem 3. Post-chemotherapy myelosuppression
Problem 4. Nutritional compromise and cachexia
Problem 5. Electrolyte and renal function status
[lab data]
2025-05-10 HBsAg Nonreactive
2025-05-10 HBsAg Value 0.27 S/CO
2025-05-10 Anti-HBc Reactive
2025-05-10 Anti-HBc Value 5.18 S/CO
2025-05-10 Anti-HCV Nonreactive
2025-05-10 Anti-HCV Value 0.11 S/CO
[exam finding]
[MedRec]
[immunochemotherapy]
The 77-year-old woman with urothelial cell carcinoma of the right renal pelvis, sarcomatoid variant, presented with multiple lung metastases (MRI 2025-05-14), clinical stage cT3N2M1 (Stage IV). She has a background of Sjogren syndrome, CKD stage 3, and hyperuricemia. After the initial cycle of immunochemotherapy (pembrolizumab + enfortumab vedotin on 2025-05-14 and 2025-05-22), she now presents on 2025-06-03–06-04 with fatigue, anorexia, and minor weight loss, but no signs of infection or progression-related dyspnea.
Current status:
Problem 1. Metastatic urothelial carcinoma (renal pelvis, sarcomatoid phenotype, cT3N2M1, stage IV)
Problem 2. Fatigue and anorexia
Problem 3. Renal function impairment (CKD stage 3)
Problem 4. Dermatologic toxicity
[exam finding]
[MedRec]
2025-01-17 ~ 2025-01-24 POMR Hemato-Oncology Lin YiTing
2025-01-09 SOAP Cardiology Zhou XingHui
2024-12-27 ~ 2025-01-04 POMR Hemato-Oncology Lin YiTing
2024-11-24 ~ 2024-11-26 POMR Cardiology Zhou XingHui
2024-07-01 ~ 2024-07-03 POMR Hemato-Oncology Gao WeiYao
2024-05-23 ~ 2024-06-09 POMR Obstetrics and Gynecology Shao ZhiXuan
2023-10-01 ~ 2023-10-04 POMR Cardiology Zhou XingHui
2023-07-18 ~ 2023-07-22 POMR Infectious Disease
2023-05-04 ~ 2023-05-20 POMR Infectious Disease
2023-02-05 ~ 2023-02-10 POMR Cardiology Zhou XingHui
2022-05-16 ~ 2022-05-25 POMR Nephrology Guo KeLin
2021-12-29 ~ 2022-01-19 POMR Nephrology Guo KeLin
2021-11-10 ~ 2021-11-23 POMR Nephrology Guo KeLin
[consultation]
2025-05-06 Nephrology
2025-04-16 Nephrology
2025-03-17 Nephrology
2025-02-24 Nephrology
2025-02-05 Nephrology
….-..-..
[surgical operation]
[chemotherapy]
This is a 56-year-old woman with:
Problem 1. Volume overload with bilateral pleural effusions and heart failure
Problem 2. Anemia (multifactorial, ESRD + inflammation + possible GI loss)
Problem 3. Advanced right ovarian cancer with peritoneal carcinomatosis (FIGO IV, BRCA-wildtype)
Problem 4. Electrolyte imbalance and uremia in ESRD (not posted)
Problem 5. Diabetes mellitus with adequate short-term glycemic control
[Key Insights / Summary]
The patient is a 56-year-old woman with advanced right ovarian high-grade serous carcinoma with peritoneal carcinomatosis (pT3cN0M1, FIGO stage IV), status post debulking surgery on 2024-05-31, receiving palliative chemotherapy with paclitaxel/carboplatin (C1-C4 completed). She also has significant comorbidities including coronary artery disease (post-PTCA for middle LCX in 2023 with persistent RCA stenosis), hypertensive heart disease, type 2 diabetes mellitus, end-stage renal disease on hemodialysis (QW135), hypothyroidism, and chronic anemia.
She was admitted on 2025-05-06 for intermittent chest tightness and abdominal bloating with bilateral pleural effusions (transudative) and worsening anemia. The current course is complicated by chronic dyspnea, moderate hypoxia (SpO₂ 95-100%), and chronic metabolic derangements. The most recent CXR (2025-05-05) showed bilateral pleural effusion and ground glass opacities. Pleural tapping confirmed transudate (pleural TP 3.7 g/dL, LDH 113 U/L) (2025-05-06).
Hematology is notable for persistent anemia (Hgb 7.4 g/dL on 2025-05-06) and chronic renal impairment (Cr 4.11 mg/dL, eGFR 11.97 mL/min/1.73m² on 2025-05-05). Blood gases revealed chronic compensated hypercapnia (PCO₂ 55.6 mmHg, HCO₃ 31.1 mmol/L) (2025-05-06). She remains on extensive supportive medications including “Coralan (ivabradine)”, “Coxine (isosorbide-5-mononitrate)”, “Diovan (valsartan)”, and “Fentanyl Transdermal Patch (fentanyl)” for heart failure and pain control.
[Problem-Oriented Deliberation]
Problem 1. Bilateral pleural effusion with dyspnea and hypoxia
Problem 2. Chronic anemia in ESRD with ongoing chemotherapy
Problem 3. Chronic heart disease with intermittent chest discomfort
Problem 4. End-stage renal disease with metabolic derangements
Problem 5. Constipation and gastrointestinal symptoms
[Patient Summary]
The patient is a 55-year-old woman with a complex medical history including right ovarian high-grade serous carcinoma with peritoneal carcinomatosis (pT3cN0M1, FIGO stage IV, s/p debulking surgery on 2024-05-31), ESRD on hemodialysis, hypertensive heart disease, type 2 diabetes mellitus, CAD (post-PTCA and stenting for middle LCX in 2023, with two-vessel disease diagnosed in 2024), and chronic anemia.
She was admitted on 2025-02-24 due to dyspnea, chest discomfort, and bilateral lower extremity edema for two days.
She is receiving Sintrix (ceftriaxone) 2000 mg IV daily for suspected left lung pneumonia and oxygen therapy. Chest ultrasound is scheduled for 2025-02-26 for possible drainage evaluation.
Overall Priorities
[Problems]
Problem 1. Left pleural effusion with suspected pneumonia
Problem 2. Volume overload due to ESRD on hemodialysis (QW135)
Problem 3. Worsening anemia with thrombocytosis
Problem 4. Advanced right ovarian carcinoma with peritoneal carcinomatosis
Key Clinical Issues:
Management Recommendations:
[Patient-Specific Oncology Management Recommendations]
Diagnosis and Staging
Histologic Type: High-grade serous carcinoma of the ovary with peritoneal carcinomatosis, AJCC 8th Edition Stage IIIC (pT3cN0M0).
Surgical Outcome:
Post-Surgical Considerations
[Adjuvant Therapy Options]
Chemotherapy
Maintenance Therapy
Surveillance and Monitoring
Additional Considerations
[exam finding]
[MedRec]
[immunochemotherapy]
[Tube Feeding Recommendations for Ninlaro (Ixazomib) and Revlimid (Lenalidomide)]
These methods for administering Ninlaro and Revlimid via tube feeding, based on off-label info from their suppliers:
Ninlaro (Ixazomib)
Revlimid (Lenalidomide)
This is an 82-year-old male with relapsed IgG-type multiple myeloma, ISS stage II, status post autologous PBSCT on 2015-01-14, with prior treatment history including thalidomide, bortezomib, daratumumab-based immunochemotherapy (DRd 2022-02 to 2023-01), and continued oral agents (lenalidomide until 2023-02, thalidomide until 2024-10). He also received bone protection with Xgeva (denosumab 120mg Q1M) until 2022-07, later replaced by Prolia (denosumab 60mg SC) from 2023-09.
Recent labs show progressively rising IgG (6230 mg/dL on 2025-05-16 → 728.98 mg/L FKLC on 2024-12-31 with κ/λ ratio >100), persistent anemia (Hb 7.6 g/dL on 2025-06-02), hypoalbuminemia, hyponatremia, and low-normal calcium. Functional status declined (ECOG PS 4 on 2025-06-03), with tube dependency and chronic comorbidities including COPD, GERD, insomnia, and benign prostatic hyperplasia.
The patient was admitted on 2025-06-02 for further evaluation and chemotherapy preparation. Imaging confirms advanced spinal involvement (multiple vertebral compression fractures including L1, T11, L2 with spondylosis), and chronic pulmonary and cardiac structural changes. Current concerns center on disease progression, symptomatic anemia, electrolyte imbalance, and performance status affecting treatment feasibility.
Problem 1. Relapsed multiple myeloma (IgG type, ISS II)
Problem 2. Anemia
Problem 3. Hyponatremia and borderline hypokalemia
Problem 4. Poor performance status and frailty (not posted)
Problem 5. COPD and chronic pulmonary changes (not posted)
[A few additional integrative and anticipatory comments may help guide further management]
Consideration:
Implication:
Consideration:
Implication:
[assessing thalidomide risks and managing complications in myeloma]
Based on the updated lab results for this patient with multiple myeloma (post-autoPBSCT in 2015 and currently on thalidomide):
General Management:
[Multifaceted Approach to Optimizing Care for the Multiple Myeloma Patient]
Based on the updated laboratory results and the clinical background of this patient with multiple myeloma who underwent autoPBSCT in 2015 and is recently managed with thalidomide, here are the findings, concerns, and management suggestions:
Overall Management Thought:
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
This is a 71-year-old woman with stage IVa distal descending colon adenocarcinoma (cT4bN2aM1a) harboring MLH1 loss (Pathology 2025-01-24) and BRAF V600E mutation (2025-02-11), with multiple liver metastases. She has been receiving biweekly Avastin (bevacizumab) + FOLFIRI chemotherapy since 2025-02-14. As of 2025-06-03 (Cycle 4 Day 15), she remains clinically stable, with tolerable side effects. Recent CT (2025-05-15) shows marked regression of primary colon cancer and stable liver metastases, suggesting partial treatment response.
She has normotensive heart disease without heart failure, no evident signs of chemotherapy-induced organ dysfunction, but persistent anemia (Hb 9.7 g/dL on 2025-06-02) and chemotherapy-induced nausea (G2), appetite loss (G2), fatigue (G1), sensory neuropathy (G1).
Problem 1. Metastatic colorectal adenocarcinoma (cT4bN2aM1a, stage IVa)
Problem 2. Chemotherapy-induced gastrointestinal toxicity (nausea G2, appetite loss G2, constipation G1)
Problem 3. Anemia (Grade 2) (not posted)
Problem 4. Chemotherapy-related fatigue and sensory neuropathy
Problem 5. Hypertension (well-controlled) (not posted)
Patient Review
Problem 1: Metastatic Colon Cancer – Response to Chemotherapy
Problem 2: Chemotherapy-Induced Nausea and Vomiting (CINV) and Headache
Problem 3: Upper Gastrointestinal Bleeding Risk (stool OB 3+) (below not posted)
Problem 4: Hypertensive Heart Disease & Cardiac Function Monitoring
Final Summary & Next Steps
[exam finding]
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[note]
A phase II randomized study of gemcitabine and nab-paclitaxel in combination with S- 1/LV (GASL) or oxaliplatin (GAP) as first-line treatment for metastatic pancreatic cancer — https://www.annalsofoncology.org/article/S0923-7534(24)03110-7/fulltext
This is a 62-year-old man with biopsy-proven ductal adenocarcinoma of the pancreatic tail, moderately differentiated, with invasion of adjacent structures (stomach, spleen, adrenal, kidney, vessels) and metastases to liver, lung, and lymph nodes, clinical stage T4N2M1, stage IV. He presents with persistent abdominal pain, cachexia, and hyperbilirubinemia, and has received first-cycle GASL chemotherapy (Gemcitabine, Abraxane, TS-1, and Leucovorin) between 2025-05-09 and 2025-05-29. He underwent ascites drainage (1500 mL, bloody) on 2025-05-19. His course is complicated by leukocytosis, refractory anemia, and liver dysfunction. As of 2025-06-02, he is afebrile and hemodynamically stable with SpO2 98–99%, and on supportive care including TPN, analgesics, and antibiotics (ceftazidime).
Problem 1. Pancreatic cancer with liver and lung metastases (T4N2M1, Stage IV)
Problem 2. Liver dysfunction and hyperbilirubinemia
Problem 3. Ascites and cachexia
Problem 4. Leukocytosis with possible infection
Problem 5. Refractory anemia (not posted)
This is a patient with a known history of diabetes mellitus (DM), leukemia (likely acute based on blast percentage), and Sicca syndrome, presenting with fever and leukocytosis. Emergency room evaluation on 2025-06-01 documented acute ill-looking appearance, high-grade fever (up to 38.8°C), tachycardia, and elevated respiratory rate. Laboratory findings indicate acute leukemia with hyperleukocytosis (WBC 17.97→12.9 x10^3/uL), high blast count (38.0%→46.5%), anemia (Hb 10.8→9.2 g/dL), and thrombocytopenia (PLT 27→52 x10^3/uL). The patient also has hypokalemia (K 2.9→3.0 mmol/L), elevated CRP (15.2 mg/dL on 2025-06-01), and microscopic hematuria and pyuria on urinalysis.
Initial impression in ER was unspecified fever. Current issues include:
Problem 1. Acute Leukemia with Hyperleukocytosis
Problem 2. Fever with Suspected Infection
Problem 3. Thrombocytopenia and Bleeding Risk
Problem 4. Hypokalemia
Problem 5. Hyperglycemia
[lab data]
2025-05-08 PIVKA-II 46879.58 mAU/mL
2025-05-07 HBsAg Reactive
2025-05-07 HBsAg (Value) 4020.07 S/CO
2025-05-07 Anti-HCV Nonreactive
2025-05-07 Anti-HCV Value 0.11 S/CO
2025-05-07 Anti-HBc Reactive
2025-05-07 Anti-HBc Value 6.38 S/CO
2025-05-07 Anti-HBs 0.28 mIU/mL
2025-05-07 Anti-HBc IgM Nonreactive
2025-05-07 Anti-HBc IgM Value 0.10 S/CO
2025-05-07 HBeAg Nonreactive
2025-05-07 HBeAg Value 0.383 S/CO
2025-05-07 HBV DNA-PCR (quan) 1080 IU/mL
2025-05-06 C3 220.7 mg/dL
2025-05-05 Ferritin (NM) 661.84 ng/ml
[exam finding]
[MedRec]
[immunotherapy]
This 54-year-old man with chronic HBV infection, liver cirrhosis (Child-Pugh A), and hepatocellular carcinoma (HCC) cT4N0M0, stage IIIB post-TAE (2025-04-23), presented on 2025-05-28 with acute chest tightness, dizziness, and was diagnosed with acute pancreatitis on CT (2025-05-28). Liver imaging consistently shows bilobar HCCs, left lobe portal vein encasement, and suspected tumor necrosis (MRI 2025-05-02; CT 2025-05-28). He has no evidence of metastatic disease (bone scan 2025-04-25). Labs suggest hepatic dysfunction with AST/ALT elevation, preserved synthetic function (albumin 3.8 g/dL, INR 1.00), and a transiently elevated D-dimer. Echocardiogram showed preserved LVEF (65.5%) with moderate to severe MR. He is receiving pain control with fentanyl patch, morphine, and tramadol, along with IO immunotherapy (Durvalumab 1500mg on 2025-05-06). No infection/sepsis signs as CRP and procalcitonin remain low. Current concerns include pancreatitis, HCC progression, hemodynamic fluctuations, and pain control.
Problem 1. Acute Pancreatitis
Problem 2. Advanced Hepatocellular Carcinoma (Stage IIIB)
Problem 3. Liver Function and Cirrhosis (Child-Pugh A)
Problem 4. Pain Management and Opioid Use
Problem 5. Hemodynamic Status and Cardiac Function
[Durvalumab and Acute Pancreatitis: An Uncommon Link]
Acute pancreatitis is a recognized but rare immune-related adverse event (irAE) associated with Durvalumab, an anti-PD-L1 immune checkpoint inhibitor. Although uncommon, cases of immune-mediated pancreatitis have been reported across checkpoint inhibitors (PD-1, PD-L1, CTLA-4), including Durvalumab and combination therapies (e.g., with Tremelimumab) (Ref).
Evaluation in this Case:
Supporting Evidence:
Conclusion:
Next Steps:
References:
[exam findings]
[MedRec]
2025-02-16 ~ 2025-02-27 POMR Hemato-Oncology He JingLiang
2025-01-07 ~ 2025-01-17 POMR Orthopedics Zhu ChungHua
2023-11-21 ~ 2023-12-08 POMR Hemato-Oncology He JingLiang
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Valcyte FC (valganciclovir 450mg/tab) tube feeding]
Valcyte F.C. (valganciclovir film-coated tablets) should not be crushed or ground due to hazardous exposure risks and potential alteration of drug delivery. For patients requiring tube feeding, the preferred and safest approach is to use the commercially available oral solution of valganciclovir, which is specifically designed for this purpose2.
However, if the oral solution is unavailable and administration via tube is absolutely necessary, a method known as the “simple suspension method” can be considered, as described in clinical research and practice guidelines4. This method should only be performed by trained healthcare professionals with appropriate precautions due to the drug’s hazardous nature.
How to Administer Valcyte via Tube Feeding (if oral solution is unavailable)
Summary Table
| Step | Details |
|---|---|
| Preferred method | Use commercial oral solution |
| If tablets only | Use simple suspension method with cracked tablet, warm water, and strict safety measures |
| Safety | Wear gloves/mask; avoid powder generation; prepare in ventilated area |
| Flushing | Flush tube before and after with 15–30 mL water |
| Feeding | Stop during administration, resume after |
References:
In summary:
Always use the oral solution for tube feeding if available. If not, the
simple suspension method can be used with extreme caution and
appropriate safety measures.
Citations:
1 https://rudiapt.files.wordpress.com/2017/11/handbook-of-drug-administration-via-enteral-feeding-tubes-2015.pdf 2 https://www.medicines.org.uk/emc/product/8177/smpc 3 https://www.scribd.com/doc/98100059/Guidelines-for-the-Adminstration-of-Drugs-via-Enteral-Feeding-Tubes 4 https://pmc.ncbi.nlm.nih.gov/articles/PMC7339454/ 5 https://www.academia.edu/19624539/2012_03_26Handbk_Of_Drug_Admini_Via_Enteral_Feeding_Tubes_1st_Ed_White_And_Bradn 6 https://www.rlandrews.org/pdf_files/handbk_of_enteralfeeding.pdf 7 https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021304s008,022257s003lbl.pdf 8 https://academic.oup.com/ajhp/article/66/16/1458/5130347 9 https://assets.hpra.ie/products/Human/30773/caa5aea4-d4b5-4e2a-9dec-19f8b6752e28.pdf 10 https://www.gene.com/download/pdf/valcyte_prescribing.pdf 11 https://www.medicines.org.uk/emc/product/14225/smpc 12 https://ugc.production.linktr.ee/d15c968f-c888-4165-ab95-197f38afbc7b_DRUG-ADMINISTRATION-VIA-NASOGASTRIC-TUBE---FOR-DYPSHAGIA-PATIENTS.pdf 13 https://assets.roche.com/f/173850/x/ad2abcc5b2/valcyte_pm_e.pdf 14 https://www.medsafe.govt.nz/profs/datasheet/v/valganciclovirmylantab.pdf 15 https://outreach.cheo.on.ca/manual/2283-0 16 https://deepblue.lib.umich.edu/bitstream/handle/2027.42/78598/j.1399-3062.2009.00478.x.pdf
Problem 1. Anemia
Problem 2. Thrombocytopenia
Here is the updated evaluation of the patient as of 2025-05-15, based on all clinical, imaging, laboratory, therapeutic, and vital data accumulated since the last review on 2025-04-25.
Problem 1. Advanced cholangiocarcinoma with liver and bone metastases
Problem 2. Persistent cytopenias post-chemotherapy (leukocytosis rebound)
Problem 3. Hepatobiliary dysfunction (transaminitis, hyperbilirubinemia)
Problem 4. Electrolyte abnormalities: hypercalcemia and hyponatremia
Problem 5. Pain related to bone metastases
Problem 6. Left chest wall skin lesion (post-herpetic)
Problem 1. Pancytopenia
Problem 2. Advanced Cholangiocarcinoma with Liver and Bone Metastases
Problem 3. Postoperative Bone Metastasis and Pathological Fracture
Problem 4. Hepatotoxicity Under Chemotherapy
Problem 5. Nutritional and Functional Status
This is a 50-year-old female with stage IV intrahepatic cholangiocarcinoma (diagnosed 2023-11-22 via liver biopsy), complicated by metastases to the liver, lymph nodes, bone (confirmed by multiple imaging and pathology), and possibly lung, with ongoing multi-line chemotherapy and radiotherapy. The patient is also a chronic hepatitis B carrier and has undergone multiple orthopedic interventions due to pathological fractures. As of 2025-03-24, the key concerns are:
Problem 1. Pancytopenia
Problem 2. Cholangiocarcinoma with Multisite Metastasis
Problem 3. Metastatic Bone Disease with Pathological Fractures
Problem 4. Chronic Hepatitis B
[potential resistance to current regimen noted]
A bone scan on 2024-04-17 indicated progression of metastatic bone disease compared to the previous study on 2023-11-23. This suggests that the disease may be developing resistance to the current regimen of durvalumab, gemcitabine, and cisplatin. Lab results on 2024-06-12 were generally normal, and no medication discrepancies were identified.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
This 65-year-old man with stage IV gastric cancer (T3N3M1, poorly cohesive type) and extensive lymph node and bone metastases has been undergoing biweekly immunochemotherapy with Opdivo (nivolumab) plus FOLFOX since 2025-01-10. As of the current hospitalization (2025-05-26), he is receiving his 10th session. His general condition remains stable with preserved organ function, tolerable chemotherapy-related adverse effects (Grade 1 fatigue, alopecia, mild leukopenia), and no active infection or organ failure. Vital signs are stable; tumor markers (CEA and CA 19-9) show a mild downward trend. Functional and nutritional status are being maintained, though anemia and mild hypocalcemia persist.
Problem 1. Metastatic gastric cancer under immunochemotherapy
Problem 2. Chemotherapy-induced anemia and leukopenia
Problem 3. Electrolyte disturbances: borderline hypocalcemia
Problem 4. Chemotherapy-related adverse effects
Problem 5. Psychosocial concern and supportive care (not posted)
Updated Patient Evaluation
Since the last review on 2025-02-04, the patient has continued nivolumab (240 mg) + FOLFOX immunochemotherapy on 2025-02-17, 2025-03-03, and 2025-03-17. There are notable trends in hematologic, renal, hepatic, and tumor marker parameters. Imaging updates confirm progression of bone metastases, and pathology findings suggest a gingival/oral mucosal ulcer without malignancy. The patient remains hemodynamically stable with manageable organ function, but persistent anemia, leukopenia, and elevated CA-199 require closer evaluation.
Problem 1. Hematologic Suppression (Anemia, Leukopenia, Thrombocytopenia)
Problem 2. Bone Metastases Progression
Problem 3. Gastrointestinal Symptoms (Diarrhea, Gastric Cancer Progression, and CA-199 Elevation) (below not posted)
Problem 4. Oral Mucosal Ulceration
Problem 5. Electrolyte and Liver Function Trends
Conclusion
The patient is a 65-year-old male diagnosed with poorly cohesive gastric carcinoma with multiple bone and lymph node metastases (T3N3M1, stage IV, as of 2025-01-03). His condition is complicated by anemia, cachexia, recurrent diarrhea, electrolyte imbalances, and evidence of parenchymal liver disease. Treatment includes immunochemotherapy (Nivolumab and FOLFOX regimen) and symptomatic management for gastrointestinal and systemic complications. The disease is progressing, as shown by PET, CT, and lab results, with persistent anemia, signs of malnutrition, and extensive metastases.
Problem 1. Anemia
Problem 2. Gastrointestinal Symptoms and Malnutrition
Problem 3. Bone Metastases and Pain
Problem 4. Electrolyte Imbalances (not posted)
Problem 5. Liver and Renal Function (not posted)
[Possibility of Other Cancers - Evaluation]
Objective Evidence
Assessment
Recommendations
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
beta-blocker related complaints
antiplatelet adherence and bleeding monitoring
dose adjustment discussion
[Objective]
cardiac recovery post-CABG
current medications (2025-05-23)
vitals and labs
[Assessment]
bradycardia and beta-blocker intolerance
post-CABG limb swelling
antiplatelet compliance
[Plan / Recommendation]
bradycardia and Concor titration
post-CABG swelling management
DAPT adherence and bleeding risk
clinical monitoring and communication
Patient Summary
Problem 1. Post-CABG Cardiac Function and Ischemia Risk
Problem 2. Pleural Effusion and Interstitial Lung Edema
Problem 3. Anemia and Postoperative Hematologic Status
Problem 4. Electrolyte and Renal Function
Problem 5. Hepatic Enzyme Elevation
[exam finding]
| mory: 2 |
|---|
| ientation: 2 |
Judgment & Problem Solving: 2
Community Affairs: 2
Home & Hobbies: 2
Personal Care: 1
CDR Score: 2
2023-08-24 MRA - brain
| mory: 2 |
|---|
| ientation: 2 |
Judgment & Problem Solving: 2
Community Affairs: 2
Home & Hobbies: 2
Personal Care: 1
CDR Score: 2
2023-08-21 Mini-Mental State Examination, MMSE
2023-08-14 2D transthoracic echocardiography
2023-08-07 CT - abdomen
2022-05-30 CT - abdomen
2018-12-28 Tc-99m MDP bone scan
2018-12-14 CT - abdomen
2018-08-30 Surgical Pathology Level VI
2018-08-29 CT - abdomen
2018-08-28 2D transthoracic echocardiography
2018-08-24 Sigmoidoscopy
| mory: 1 |
|---|
| ientation: 1 |
Judgment & Problem Solving: 1
Community Affairs: 1
Home & Hobbies: 1
Personal Care: 0
CDR Score: 1
2023-08-21 Mini-Mental State Examination, MMSE
2018-08-10 Surgical Pathology Level IV
2018-07-02 2D transthoracic echocardiography
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[note]
Cetuximab: Drug information - 2025-05-28 - https://www.uptodate.com/contents/cetuximab-drug-information
This is a 78-year-old woman with a complex oncologic history of:
She presented on 2025-05-26 with oral pain, poor intake, general weakness, and was admitted from the ED. Laboratory and clinical assessments revealed worsening mucositis (Grade 3), neutrophil predominance (82.7%), elevated CRP (12.2 mg/dL), borderline hypocalcemia (Ca 2.19 mmol/L), weight loss (down to 41 kg), but preserved vital signs and kidney/liver function.
Current clinical status is complicated by treatment-induced mucosal toxicity, nutritional decline, systemic inflammation, and potential secondary infection. Radiation and cetuximab toxicity must be critically evaluated and managed.
Problem 1. Severe oral mucositis and malnutrition
Problem 2. Locoregionally advanced recurrent tongue cancer under Bio-RT
Problem 3. Chronic inflammation and possible secondary infection
Problem 4. Electrolyte and renal profile monitoring (not posted)
Problem 5. Frailty and functional decline
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[note]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in patients who are medically fit - 2025-05-28 - https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit
This 66-year-old male with relapsed/refractory follicular lymphoma (grade 3A, stage IV, FLIPI = 5) is undergoing salvage immunochemotherapy with modified R-ESHAP. He presents with recurrent post-renal AKI (requiring right PCN), sepsis with recent shock episode (norepinephrine use prior to transfer on 2025-05-27), persistent neutropenia, fluctuating cytopenias, anal abscess status post fistulectomy, poorly controlled diabetes (HbA1c 9.1%), and atrial fibrillation with RBBB. On 2025-05-28, he shows signs of clinical stabilization under Sintum (ceftazidime) and Targocid (teicoplanin), improved hemodynamics (BP 95–109/68–80 mmHg, SpO2 100%) and afebrile status (35.9–36.1°C). However, persistent inflammation (CRP 21.0 mg/dL on 2025-05-28) and worsening anemia/thrombocytopenia are concerning.
Problem 1. Acute Kidney Injury (post-renal/intrinsic)
Problem 2. Sepsis with Neutropenia
Problem 3. Hematologic Toxicity (Anemia, Thrombocytopenia, Neutropenia)
Problem 4. Diabetes Mellitus, Poorly Controlled
Problem 5. Cardiopulmonary Compromise
Problem 6. Anal Abscess and Post-Fistulectomy Care
[MedRec]
[exam finding]
[MedRec]
[consultation]
This 68-year-old woman with advanced pancreatic head ductal adenocarcinoma (pT2N2, stage III), status post-Whipple procedure (2024-06-05) and portal vein stenting (2024-06-14), recently completed chemotherapy on 2025-05-15 and was transferred for terminal care. She experienced a fall with right frontal scalp trauma on 2025-05-23. Currently, she presents with multiple critical complications including: neutropenia with recovery trend, thrombocytopenia, persistent jaundice and hypoalbuminemia, metabolic alkalosis with hypoxemia, and signs of sepsis with elevated inflammatory markers and mixed urinary infection. Hospice co-care has been arranged due to deteriorating general status and ECOG 4. Do-not-resuscitate orders and advance directives were completed.
Problem 1. Sepsis and possible infection focus
Problem 2. Hematological suppression: neutropenia, thrombocytopenia
Problem 3. Hepatobiliary dysfunction: jaundice, hypoalbuminemia
Problem 4. Electrolyte disturbances: hyponatremia, hypokalemia, hypocalcemia
Problem 5. Acid-base and oxygenation status (based on venous blood gas)
[exam finding]
[consultation]
This is a 78-year-old male with a history of hypertension and spinal surgery, presenting with dizziness, nausea/vomiting, epigastric discomfort, and recent constitutional symptoms. Abdominal CT (2025-05-26) suggests necrotic paraaortic and retroperitoneal lymphadenopathy with liver metastases and gallbladder wall thickening, raising suspicion for gallbladder (GB) cancer. He presents with electrolyte disturbances (notably severe hyponatremia and hypocalcemia), liver dysfunction, and elevated inflammatory markers. There is also evidence of low blood osmolality and inappropriately concentrated urine. Clinical and imaging findings suggest paraneoplastic syndrome or hepatic dysfunction-associated SIADH. Surgical intervention is deferred due to advanced disease spread.
Problem 1. Suspected gallbladder cancer with lymph node and liver metastases
Problem 2. Hyponatremia
Problem 3. Hypocalcemia
Problem 4. Constitutional symptoms and nutritional deficiency
Problem 5. Pain and functional status
[lab data]
2025-04-29 Bone Marrow Chromosome Analysis
2025-04-15 B2-Microglobulin 36471 ng/mL
2025-04-14 HBsAg Nonreactive
2025-04-14 HBsAg (Value) 0.33 S/CO
2025-04-14 Anti-HBs 57.98 mIU/mL
2025-04-14 Anti-HBc Reactive
2025-04-14 Anti-HBc-Value 1.11 S/CO
2025-04-14 Anti-HCV Reactive
2025-04-14 Anti-HCV Value 2.63 S/CO
2025-04-11 FKLC 145.20 mg/L
2025-04-11 FLLC 173.23 mg/L
2025-04-11 FK/FL ratio 0.84 ratio
2025-04-09 Protein, total 10.4 g/dL
2025-04-09 Albumin 27.8 %
2025-04-09 Alpha-1 3.5 %
2025-04-09 Alpha-2 9.3 %
2025-04-09 Beta 6.1 %
2025-04-09 Gamma 53.3 %
2025-04-09 M-peak Positive
2025-04-09 A/G Ratio 0.40
2025-04-09 IgG/A/M Kappa/Lambda IgG + Kappa chain
2025-04-07 IgG (blood) 7193 mg/dL
2025-04-07 IgA 40 mg/dL
2025-04-07 IgM <20 mg/dL
2025-04-02 SCC (NM) 3.32 ng/mL
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
The patient is a 54-year-old male with multiple myeloma (IgG/Kappa, ISS stage III), end-stage renal disease on chronic hemodialysis, chronic atrial fibrillation, and heart failure with preserved ejection fraction (HFpEF). He is currently on VTd chemotherapy (bortezomib, dexamethasone, thalidomide) and antiviral prophylaxis with Vemlidy (tenofovir alafenamide). He was admitted for fever (39.6°C on 2025-05-22) and elevated hs-Troponin I (79.9 pg/mL), raising concern for possible infectious and/or cardiac complications. Imaging on 2025-05-21 suggests cardiomegaly and left lower lung field opacity. The myeloma remains uncontrolled, and the patient’s condition is complicated by anemia, electrolyte disturbances, and systemic inflammation.
Problem 1. Fever with left lung opacity
Problem 2. Active multiple myeloma (IgG/Kappa)
Problem 3. End-stage renal disease on hemodialysis
Problem 4. Atrial fibrillation and cardiac risk
Problem 5. Anemia and inflammatory state
[exam finding]
[MedRec]
2024-12-18 ~ 2024-12-25 POMR Neurology Chen GuiQuan
2024-08-27 ~ 2024-09-12 POMR General and Gastroenterological Surgery Wu ChaoQun
2023-03-07 ~ 2023-03-10 POMR Urology Luo QiWen
2022-08-22 ~ 2022-08-25 POMR Urology Luo QiWen
[consultation]
[surgical operation]
[chemotherapy]
The patient is a 75-year-old male with stage IB signet-ring cell adenocarcinoma of the gastric antrum (pT1bN1cM0), status post laparoscopic subtotal gastrectomy with D2 lymphadenectomy on 2024-08-29, currently undergoing adjuvant chemotherapy with FOLFOX, most recently administered on 2025-05-23. He has a background of chronic hepatitis B and a prior ischemic stroke (left MCA infarct on 2024-12-17). The patient remains ECOG 1 with stable vital signs. Recent labs on 2025-05-22 reveal microcytic anemia, mild thrombocytopenia, and CKD stage 2 with stable liver function. No signs of infection or recurrence noted on imaging or physical exam.
Problem 1. Gastric cancer (post-gastrectomy, stage IB)
Problem 2. Microcytic anemia (below not posted)
Problem 3. Thrombocytopenia
Problem 4. Chronic hepatitis B
Problem 5. Renal function (CKD stage 2)
Problem 6. Ischemic stroke history
This is a 75-year-old male with a history of gastric adenocarcinoma with signet-ring cell differentiation (pT1bN1, Stage IB) post-laparoscopic subtotal gastrectomy with D2 lymph node dissection on 2024-08-29. He has since received 8 cycles of FOLFOX chemotherapy, adjusted in later courses due to cytopenia. The patient also experienced a focal left MCA infarct on 2024-12-17, with residual partial aphasia. Comorbidities include chronic hepatitis B, right bundle branch block, LV diastolic dysfunction, and cerebral atrophy with small vessel disease. His recent labs on 2025-03-24 reveal persistent microcytic anemia, mild hypoalbuminemia, and renal function within CKD stage 2 range. Current vital signs are stable.
Problem 1. Gastric Adenocarcinoma (Post-Gastrectomy, pT1bN1, Stage IB)
Problem 2. Ischemic Stroke (Left MCA Infarct, 2024-12-17)
Problem 3. Microcytic Anemia (Chronic, Symptomatic)
Problem 4. Chronic Hepatitis B
Problem 5. Mild Renal Dysfunction (CKD Stage 2) (not posted)
Problem 6. Cardiac Conduction and Structural Abnormalities
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This 68-year-old man with high-grade, nonintestinal-type left sinonasal adenocarcinoma (T1N2bM1, stage IVc) status post tumor excision (2024-05-31), presents post-auto-PBSCT (2025-04-09), currently on self-paid palliative chemotherapy with Taxotere (docetaxel). Disease is metastatic to left parotid, mandible (perineural spread), lymph nodes, lung, and bone (notably C6). Based on MRI (2025-04-11), disease burden is stable. He received Cycle 6 docetaxel on 2025-05-22 with stable performance (ECOG PS 1), afebrile, no pain, and preserved appetite. Labs show stable renal function (eGFR ~34.3 mL/min/1.73m² on 2025-05-21), chronic mild anemia (HGB 10.2 g/dL on 2025-05-21), normokalemia, hyperuricemia, and hypo-HDL pattern. He is maintained on Vemlidy (tenofovir alafenamide) for HBV reactivation prophylaxis. A bone scan and radiotherapy planning are underway.
Problem 1. Metastatic sinonasal adenocarcinoma (T1N2bM1, stage IVc)
Problem 2. Bone metastasis (C6 vertebral body)
Problem 3. Chronic hepatitis B carrier
Problem 4. Anemia
Problem 5. Chronic renal dysfunction
Problem 6. Hyperuricemia
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
medication counseling for adjuvant endocrine therapy
prior therapy and surgical history
[Objective]
oncologic staging and pathology
current treatment
labs and comorbid status
[Assessment]
early-stage HR+/HER2– breast cancer with AI initiation
potential adverse effects of AI requiring monitoring
medication safety and adherence considerations
[Plan / Recommendation]
optimize AI therapy monitoring and supportive measures
education and follow-up
This is a postmenopausal woman with hormone receptor (HR)-positive, HER2-negative early-stage (pT1aNx) invasive ductal carcinoma of the left breast, coexisting with ductal carcinoma in situ (DCIS) involving the resection margin after partial mastectomy (2025-05-19). The invasive tumor is ER/PR strongly positive, HER2 negative, and Ki-67 low (10%). No nodal assessment was performed. Background history includes hypertension, dyslipidemia, insomnia, and peptic ulcer disease, all under pharmacologic management. Bone scan (2025-04-30) revealed a solitary skull hot spot and multiple suspected benign skeletal lesions, pending follow-up. Liver and renal function are preserved. ECG abnormalities (2025-05-15) raise concern for chronic cardiac ischemia. Current staging is pT1aNxM0, Stage IA (AJCC 8th).
Problem 1. Breast cancer (HR+/HER2–, pT1aNxM0)
Problem 2. Cardiovascular disease and abnormal ECG
Problem 3. Hepatobiliary lesions and bone scan abnormality
Problem 4. General metabolic and hematological status
[MedRec]
[exam finding]
[MedRec]
[immunochemotherapy]
[Note]
Pertuzumab, trastuzumab, and hyaluronidase: Drug information - 2025-05-21 - https://www.uptodate.com/contents/pertuzumab-trastuzumab-and-hyaluronidase-drug-information
Systemic therapy regimens for HER2-positive breast cancer: Neoadjuvant trastuzumab, pertuzumab, carboplatin, and docetaxel followed by adjuvant trastuzumab - 2025-05-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F96372
Cycle length: Every 21 days.
Duration of therapy: Prior to surgery (neoadjuvant portion of treatment), administer carboplatin, docetaxel, trastuzumab, and pertuzumab every 21 days for six cycles. Following surgery, adjuvant treatment consists of 11 cycles of trastuzumab alone to complete one year of trastuzumab.
Regimen
Systemic therapy regimens for HER2-positive metastatic breast cancer: Pertuzumab, trastuzumab, and docetaxel - 2025-05-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F96342
Cycle length: Every 21 days.
Duration of therapy: Until disease progression or unacceptable toxicity.
Regimen
[Subjective]
Chemotherapy-related diarrhea and pain
Anemia-related symptoms and education
Bone metastasis management
Hepatitis B risk and antiviral prophylaxis
[Objective]
Laboratory trends
Medication
Treatment summary
[Assessment]
Post-chemotherapy diarrhea and mucosal toxicity
Chemotherapy-induced anemia
Bone metastasis
Hepatitis B risk under immunosuppression
[Plan / Recommendation]
Symptom monitoring and medication counseling
Anemia follow-up and management
Bone-modifying agent initiation
HBV prophylaxis
This is a 72-year-old female with HER2-positive (ER+, PR−, Ki-67: 70%) left breast invasive carcinoma (NST type), stage IV (cT3N0M1) with confirmed metastases to the right supraclavicular lymph nodes, bone (including S1-S2, L5, costovertebral junctions), and possibly mediastinal lymph nodes (PET 2025-04-08; CT 2025-04-07; Bone Scan 2025-04-09). She began systemic therapy with the TCHP regimen on 2025-04-26 and received a second cycle with Phesgo and docetaxel on 2025-05-19. Complications have included chemotherapy-induced diarrhea (hospitalization 2025-05-01 to 2025-05-06), transient neutropenia, anemia, hyponatremia, and cancer-related fatigue with reduced oral intake. Functional performance has declined (ECOG from 0 to 1), and her weight has dropped from 58 kg to 54.3 kg over 1 month. Despite this, major organ functions (renal, liver, cardiac) remain relatively preserved.
Problem 1. Metastatic HER2-positive left breast cancer (stage IV, cT3N0M1)
Problem 2. Chemotherapy-related complications (diarrhea, neutropenia, fatigue)
Problem 3. Anemia, possibly multifactorial
Problem 4. Electrolyte imbalance – hyponatremia
Problem 5. Bone metastasis with pain and limited mobility
[Justification based on NCCN 2025 Guidelines]
The treatment plan in Problem 1 does not violate the 2025 NCCN guidelines for HER2-positive breast cancer. On the contrary, it is well-aligned with current NCCN recommendations.
Patient Context:
NCCN-Supported Regimen:
According to the NCCN 2025 Guidelines for HR-positive, HER2-positive Stage IV breast cancer, the preferred first-line systemic therapy includes:
This combination is based on the CLEOPATRA trial, which demonstrated significant improvement in progression-free and overall survival for HER2-positive metastatic breast cancer.
Furthermore, Carboplatin is also an acceptable substitution in taxane-based HER2 regimens when clinically appropriate or when tolerance/toxicities are a concern.
Phesgo, a fixed-dose subcutaneous formulation of trastuzumab and pertuzumab, is approved and endorsed in the NCCN guideline as a substitute for the separate IV agents, offering comparable efficacy and safety.
Conclusion:
[exam finding]
[MedRec]
[immunochemotherapy]
[Concentrated IV Valproate for Fluid Restriction]
For patients requiring fluid restriction, the concentration of intravenous valproate sodium (Depakine) can be increased up to 8 mg/mL, provided that the infusion rate does not exceed 20 mg/min and the solution is diluted in at least 50 mL of a compatible diluent such as normal saline (NS) or 5% dextrose in water (D5W). (GlobalRPH)
Rationale:
Clinical Application:
Precautions:
Conclusion:
In fluid-restricted patients, administering valproate sodium at a concentration of up to 8 mg/mL in a minimum of 50 mL of compatible diluent over 60 minutes is acceptable and aligns with current guidelines.(GlobalRPH)
The Depakine 400mg/vial package insert recommends dissolving in 500mL of solution (0.8mg/mL). However, due to fluid restriction concerns, it is conservatively recommended to dissolve in 100mL (4mg/mL) and administer over 120 minutes.
References:
[exam finding]
[consultation]
This 65-year-old woman with multiple myeloma (IgA, stage III), end-stage renal disease on hemodialysis since 2023-01-12, and congestive heart failure (initial LVEF 22%, now normalized), is currently hospitalized for suspected myeloma relapse. Bone marrow biopsy on 2025-04-29 demonstrated histological features consistent with relapse, supported by rising lambda light chains and anemia. She also presents with an infected left AV graft, complicating vascular access for dialysis. Diabetes control remains suboptimal, with postprandial glucose excursions despite insulin use. Renal function is chronically impaired but stable. Cardiopulmonary and hemodynamic status are currently stable without evidence of fluid overload or respiratory compromise.
Problem 1. Multiple myeloma (IgA, relapsed)
Problem 2. End-stage renal disease with left AV graft infection
Problem 3. Anemia
Problem 4. Type 2 diabetes mellitus with hyperglycemia
Problem 5. Heart failure with preserved ejection fraction (LVEF normalized)
[exam finding]
[MedRec]
[exam finding] (not completed)
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[exam finding]
[MedRec]
[Subjective]
medication adherence and safety monitoring
bleeding risk counseling
[Objective]
antiplatelet and cardiovascular medication review - on Bokey (aspirin 100 mg QD) and Plavix (clopidogrel 75 mg QD) - on Concor (bisoprolol 5 mg QD), Diovan FC (valsartan 80 mg QD), Crestor (rosuvastatin 10 mg QD), Spiron (spironolactone 25 mg QD)
glycemic control regimen
BP/glucose trend
recent labs and hemodynamic status
[Assessment]
medication adherence adequate
no current bleeding or cardiovascular complications
glycemic status improved, but high-risk background persists
[Plan / Recommendation]
monitor for bleeding complications
reinforce medication and lifestyle adherence
glycemic follow-up and titration
BP monitoring and threshold guidance
A 78-year-old male with a long-standing history of type 2 diabetes mellitus and hypertension presented on 2025-04-09 with NSTEMI complicated by cardiogenic shock. Coronary angiography revealed critical LM and triple-vessel disease (Syntax score 40.5) including m-LAD near-total occlusion. He underwent POBA to m-LAD and LM on 2025-04-10, required IABP support until 2025-04-13, and received CABG on 2025-04-15. He subsequently stabilized, was transferred from SICU to the ward, and was discharged on 2025-04-25 under stable condition with a comprehensive medication plan.
Problem 1. Coronary artery disease with high-risk anatomy post-NSTEMI and CABG
Problem 2. Cardiogenic shock status post-IABP support
Problem 3. Anemia and thrombocytopenia post-operatively
Problem 4. Acute inflammatory response with transient renal impairment
Problem 5. Diabetes mellitus with poor long-term control
[exam finding]
[MedRec]
[Subjective]
medication use and lifestyle
[Objective]
current pharmacotherapy (2025-05-13 SOAP)
lipid trend
recent cardiovascular interventions
LV function (2024-12-16 Echo)
[Assessment]
dual antiplatelet therapy
lipid control
lifestyle and secondary prevention
[Plan / Recommendation]
antiplatelet therapy
lipid management
lifestyle reinforcement
surveillance
This is a 45-year-old male with a significant history of ST-elevation myocardial infarction (STEMI) on 2024-12-14, due to dual-vessel coronary artery disease (CAD) involving the LCx-OM1 and LAD. He underwent staged PCI with drug-eluting stents (DES) to the LCx-OM1 and P-LCx (2024-12-14), followed by M-LAD and P-LAD stenting (2025-01-13). He remains on DAPT (aspirin + ticagrelor) with high-intensity lipid-lowering therapy (atorvastatin/ezetimibe + PCSK9 inhibitor alirocumab). He is currently clinically stable without recurrent angina, though he reports exertional dyspnea. His LV systolic function is borderline (EF ~50%) with lateral wall hypokinesia, and labs show marked LDL-C reduction post-treatment (199 → 14 → 73 mg/dL), indicating excellent lipid response.
Problem 1. Coronary Artery Disease with STEMI, post-PCI x4 DES (LCx-OM1, P-LCx, M-LAD, P-LAD)
Problem 2. Borderline LV Systolic Dysfunction with Regional Wall Motion Abnormality
Problem 3. Dyslipidemia with Recent LDL-C Normalization
Problem 4. Hypertension, well controlled
Problem 5. Active Smoking and Lifestyle Risk
Problem 6. Hypokalemia (corrected)
[lab data]
2025-02-12 CMV_IgG Reactive
2025-02-12 CMV_IgG Value 1165.6 AU/mL
2024-11-05 HLA A-high 11:02 2024-11-05 HLA A-high 33:03 2024-11-05 HLA B-high 38:02 2024-11-05 HLA B-high 58:01 2024-11-05 HLA C-high 03:02 2024-11-05 HLA C-high 07:02 2024-11-05 HLA DQ-high 05:03 2024-11-05 HLA DQ-high 06:09 2024-11-05 HLA DR-high 13:02 2024-11-05 HLA DR-high 14:54
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
2025-03-02 cyclophosphamide 40mg/kg 3400mg NS 500mL 4hr D1-2
2025-02-20 - fludarabine 24mg/m2 50mg NS 250mL 1hr D1-5 + busulfan 3.2mg/kg 276mg NS 460mL 3hr D2-4 (PTCy TBI ATG. Fludara 20% off, poor renal function)
2024-11-19 - rituximab 375mg/m2 760mg NS 500mL 8hr D1 + ifosfamide 5000mg/m2 10000mg NS 500mL 24hr D4 + mesna 5000mg/m2 10000mg NS 500mL 24hr D4 + carboplatin AUC 5 430mg NS 100mL 3hr D4 + etoposide 100mg/m2 200mg NS 500mL 1hr D3-5 (R-ICE)
2024-10-23 - rituximab 375mg/m2 760mg NS 500mL 8hr D1 + ifosfamide 5000mg/m2 10000mg NS 500mL 24hr D4 + mesna 5000mg/m2 10000mg NS 500mL 24hr D4 + carboplatin AUC 5 430mg NS 100mL 3hr D4 + etoposide 100mg/m2 200mg NS 500mL 1hr D3-5 (R-ICE)
2023-05-30 - etoposide 500mg/m2 1000mg NS 50mL 2hr D1-4 (high dose etoposide. Once)
2022-06-02 - 2024-07-19 - Imbruvica (ibrutinib) 140mg/cap 4# QD
2022-04-11 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-03-11 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP)
2022-02-08 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-01-04 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min ………………………….. + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-12-08 - ……………………………………………………….. cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-12-07 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-11-16 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-10-19 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min ………………………….. + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 30mg BID PO D1-5
Problem 1: Post-Allo PBSCT Immune Reconstitution and Engraftment
Problem 2: GVHD Prophylaxis – Cyclosporine A Level Monitoring
Problem 3: Thrombocytopenia
Problem 4: Electrolyte Imbalances (Mg, Ca, Na)
Problem 5: Glycemic Control in a Diabetic Post-Transplant
Problem 6: Infection Risk and Management
[evaluation of whether the post-allo PBSCT patient is ready for hospital discharge]
Final Comment: Is this patient ready for discharge?
Not quite yet.
The main barrier is platelet count (<50K) and borderline neutrophil recovery (ANC ~900). For a post-allo PBSCT patient at D+30, early discharge could be unsafe unless: - PLT reaches >50K without transfusion needs. - ANC consistently >1000/uL. - Close outpatient monitoring (labs, GVHD surveillance) is guaranteed.
What could be done before discharge: (not posted)
The patient, a 68-year-old male post-allo PBSCT (D+27 on 2025-03-25) for Mantle Cell Lymphoma (MCL), is gradually recovering from profound neutropenia. Recent data reveal:
Hematologic Reconstitution after PBSCT
GVHD Prophylaxis / Cyclosporine Management
Persistent Anemia and Thrombocytopenia
Infection Risk and Antibiotic Management
Glycemic Control
Problem 1. Profound Pancytopenia Post-AlloPBSCT
Problem 2. Cyclosporin A (CsA) Trough Level & Toxicity Risk (new data pending, not posted)
Problem 3. Diarrhea & Perianal Skin Breakdown (GVHD vs. Drug/TPN-related) (not posted)
Problem 4. Nutritional Deficiency & Refeeding Risk
Problem 5. Infection Monitoring & Antibiotic Adjustment
Updated Prioritized Issues Since 2025-03-18
Problem 1. Hematologic Recovery & Engraftment Progress
Problem 2. Cyclosporine (CsA) Trough Level Evaluation (not posted)
Problem 3. Nutritional Status & GI Function
Problem 4. Persistent Thrombocytopenia
Problem 5. Electrolyte Balance & Renal Function
Problem 6. Infection Surveillance & Antibiotic Management
Updated Insights on Prioritized Issues Since 2025-03-14
Problem 1. Post-Transplant Engraftment and Bone Marrow Recovery
Problem 2. Cyclosporine Trough Level Evaluation
Problem 3. Persistent Malnutrition and Protein Deficiency
Problem 4. Inflammatory Response and Infection Risk
Problem 5. Electrolyte Imbalances and Supplementation Needs
Final Summary of Prioritized Issues (2025-03-18)
Evaluation for Major Updates & Clinical Trends Since Last Review on 2025-03-11 (As of today 2025-03-14)
A. Key Updates and Trends (not posted)
Low-grade fever continues (BT 37.5–37.7°C) with anal pain and sore throat, raising suspicion for:
Worsening diarrhea after elemental diet, raising concern for infection-associated diarrhea (C. difficile, viral enteritis) vs. GVHD enteritis.
Cyclosporine level spiked to 404.1 ng/mL on 2025/03/13, potentially contributing to toxicity, nephrotoxicity, and immune suppression, exacerbating infection risk.
Current Infection Management:
B. Problem-Oriented Deliberation
Problem #1: Persistent Severe Pancytopenia (D+15)
Problem #2: Infection Risk with New Fever and Diarrhea
Problem #3: Cyclosporine Toxicity Risk (not posted)
Problem #4: Severe Oral Mucositis (Grade 3)
Problem #5: Nutritional Status and Metabolic Support
C. Summary of Recommendations
Overall Prognostic Considerations
Next Steps
Cyclosporine Dose Adjustment Recommendation:
[tube feeding]
Since the last review on 2025-03-07, the patient has shown changes across multiple systems:
Problem #1: Post-Haploidentical PBSCT Status (D+11)
Problem #2: Gastrointestinal Recovery and Electrolyte Imbalance
Problem #3: Grade 3 Oral Mucositis – Severe Pain and Malnutrition Risk
Problem #4: Aspiration Pneumonia (Right Lower Lobe) – Stable (not posted)
Additional Monitoring & Next Steps
Conclusion
Patient Evaluation Since Last Review (2025-03-04 → 2025-03-07 D+8 post-haploidentical PBSCT)
Problem 1: Persistent Severe Neutropenia
Problem 2: High Infection Risk (Bacterial & Fungal)
Problem 3: Severe Electrolyte Imbalances (Hypokalemia, Hyponatremia, Hypocalcemia, Hypophosphatemia)
Problem 4: Persistent Severe Thrombocytopenia
Problem 5: Liver Function Trends (Mild Recovery, But Bilirubin Rising)
Problem 6: Hyperglycemia Fluctuations
Problem 7. Diarrhea (Possible Etiologies: Electrolyte Loss, Infection, GVHD, Medications)
[Dosage Adjustment Recommendation for Atorvastatin with Cyclosporine Co-Administration]
The atorvastatin package insert states that concomitant use of cyclosporine and atorvastatin increases the bioavailability of atorvastatin, thereby raising the risk of myopathy. Therefore, it is recommended to adjust the dosage from 0.5# QD to 0.5# QOD.
Since the last evaluation on 2025-02-27, the patient has undergone haploidentical peripheral blood stem cell transplantation (PBSCT) on 2025-02-27 (D+0) and is now post-transplant D+5 (2025-03-04). The major clinical concerns in this period include:
Problem 1: Post-Transplant Cytopenia
Problem 2: Persistent Diarrhea and GI Infection Risk
Problem 3: Hepatic Dysfunction and Transaminitis
Problem 4: Electrolyte Imbalances (Hyponatremia, Hypokalemia)
Problem 5: Infection Risk and Prophylaxis
Conclusion
Since last review on 2025-02-17, the patient underwent conditioning chemotherapy (fludarabine, busulfan, cyclophosphamide), total body irradiation (TBI), and anti-thymocyte globulin (ATG) in preparation for haploidentical peripheral blood stem cell transplantation (haplo-PBSCT), which was performed on 2025-02-27 (Day 0) today.
Key developments since the last review:
Problem 1: Post-HCT Immune Reconstitution and Infection Risk
Problem 2: Hepatic Dysfunction (Post-Conditioning Transaminitis)
Problem 3: Persistent Renal Impairment
Problem 4: Thrombocytopenia and Engraftment Monitoring
Problem 5: Pulmonary Findings and Cardiac Monitoring
Summary of Next Steps
| Issue | Current Status | Action Plan |
|---|---|---|
| Post-HCT Infection Risk | Profound lymphopenia | CMV PCR monitoring, infection prophylaxis (Cravit, Micafungin, Neomycin) |
| Hepatic Dysfunction | AST/ALT elevated (647/498) | Monitor LFTs, consider VOD workup if bilirubin rises |
| Renal Function | Mild CKD | Hydration, avoid nephrotoxins |
| Thrombocytopenia | PLT 47 ×10³/uL | Monitor CBC, transfusion as needed |
| Pulmonary Findings | CXR: Possible effusion | Monitor for fluid overload, repeat imaging if needed |
Final Thoughts
The patient continues to show:
Problem 1. Persistent Bone Marrow Suppression (Anemia and Thrombocytopenia)
Problem 2. Worsening Renal Function (CKD Stage 3b)
Problem 3. Infection and Inflammation Surveillance (No Current Evidence of Active Infection)
Problem 4. Liver and Coagulation Function (Stable and Normal)
Summary of Recommendations (2025-02-17 Update, not posted)
| Problem | Current Status | Recommended Action |
|---|---|---|
| Persistent marrow suppression | Anemia (HGB 10.4), thrombocytopenia (PLT 109) | Monitor CBC, consider bone marrow biopsy (BMBx) |
| Renal impairment (CKD 3b) | Worsening Cr (1.74), eGFR 41.8 | Hydration, avoid nephrotoxins, nephrology consult if worsening |
| Infection risk (immunosuppression) | No active infection (CRP 0.1, WBC normal) | CMV PCR test, infection prophylaxis |
| Liver and coagulation function | Stable (AST/ALT, bilirubin, INR normal) | Routine monitoring |
Next Steps for Allo-PBSCT Feasibility (not posted)
The patient remains a potential candidate for allo-PBSCT, but key requirements must still be addressed:
[Assessment of Donor-Recipient Compatibility and Readiness for Haploidentical Peripheral Blood Stem Cell Transplantation (Haplo-PBSCT)]
The patient is a 66-year-old male with mantle cell lymphoma (Lugano stage IV, MIPI 6.4, intermediate risk, PS 1), type 2 diabetes mellitus, and chronic hepatitis B. He has undergone multiple lines of chemotherapy, including R-CHOP, R-DHAP, and R-ICE, and was on Imbruvica (ibrutinib) from 2022-06-02 to 2024-07-19. The most recent chemotherapy was C2 R-ICE on 2024-11-19. Current issues of concern include:
Problem 1. Persistent Bone Marrow Involvement and Cytopenia
Problem 2. Renal Impairment (CKD Stage 3)
Problem 3. Hematologic Abnormalities (Anemia, Thrombocytopenia, Lymphopenia)
Problem 4. Cardiac Conduction Abnormalities (1st Degree A-V Block)
Problem 5. Residual Lymphadenopathy and Splenomegaly (Partial Response on PET)
[Assessment for Allogeneic Peripheral Blood Stem Cell Transplant (allo-PBSCT)]
Current Indications for Allo-PBSCT
Conditions Already Met for Allo-PBSCT:
Conditions Not Yet Met (Requires Further Intervention):
This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT).
The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.
[exam finding]
2025-11-19 CXR
2025-11-17, 2025-11-14 CXR
2025-11-11 Pathology
2025-11-11 Sonography - nephrology
2025-11-10 Colonoscopy
2025-11-10 Esophagogastroduodenoscopy, EGD
2025-11-06 24hr portable ECG
2025-11-05 CXR
2025-11-04 04:38 ECG
2025-11-04 2D transthoracic echocardiography
2025-11-01 13:46 ECG
2025-10-31 Sonography - abdomen
2025-10-21 ECG
2025-10-01 Pathology - lymphnode biopsy
2025-08-27 PET
2025-08-04 CT - abdomen
2025-04-23 CT - abdomen
2025-02-21, 2025-01-24, 2025-01-20 CXR
2025-01-17 2D transthoracic echocardiography
2025-01-14 ECG
2025-01-14 Sonography - chest
2025-01-07 CXR
2024-12-19 Sonography - abdomen
2024-11-01 Sonography - chest
2024-10-30 CXR
2024-10-29 Esophagogastroduodenoscopy, EGD
2024-10-26 CT - abdomen
2024-10-14 Pathology - bone marrow biopsy
2024-10-11 PET
2024-10-08 Body fluid cytology
2024-10-08 Pathology - peritoneum biopsy
2024-10-04 15:23 Surgical pathology Level IV
2024-10-04 15:22 Pathology - stomach biopsy
2024-10-04 2D transthoracic echocardiography
2024-10-04 Esophagogastroduodenoscopy, EGD
2024-10-01 CT - abdomen
2024-09-30 ECG
2024-09-30 Body fluid cytology
2024-09-30 Ascites tapping
2024-09-30 Sonography - abdomen
2024-09-10 CXR
2024-09-09 Pathology - stomach biopsy
2024-09-06 Esophagogastroduodenoscopy, EGD
2024-09-04 Sonography - chest
2024-09-03 CT - abdomen
2024-09-03 ECG
2024-04-30 Fundus Color Photography
[MedRec]
2025-10-14 SOAP Metabolism and Endocrinology Hu YaHui
2025-10-14, 2025-08-19, 2025-03-11 SOAP Nephrology Lin DingYun
2025-10-07 SOAP Hemato-Oncology Gao WeiYao
2025-09-29 ~ 2025-10-01 POMR Hemato-Oncology Gao WeiYao
2025-09-02 SOAP Cardiology Xu ShunYi
2025-08-19 SOAP Metabolism and Endocrinology Hu YaHui
2025-04-15 SOAP Cardiology Xu ShunYi
2025-03-17 SOAP Metabolism and Endocrinology Hu YaHui
2024-09-25 ~ 2024-10-22 POMR Hemato-Oncology Gao WeiYao
[immunochemotherapy]
Key Insight/Summary
Problem 1. Relapsed/Progressive Diffuse Large B-Cell Lymphoma
Problem 2. Progressive Chronic Kidney Disease (Stage 4) with Chronic Parenchymal Damage
Problem 3. Recurrent Pleural Effusion and Ascites
Problem 4. Cardiovascular Abnormalities (Conduction Disorders, Atrial Fibrillation Episodes, LV Hypertrophy)
Problem 5. Chronic Anemia
Problem 6. Chronic Hepatitis B With Delta-Agent Under Immunosuppression
Problem 7. Glycemic Control in the Setting of Steroid Use and CKD
Problem 8. Electrolyte Abnormalities and Hypoalbuminemia
[Nakasser SR for tube feeding]
Medication: Nakasser SR 120mg/cap (diltiazem)
Issue: Sustained-release (SR) formulation is not designed for enteral tube administration and crushing/opening risks dose dumping and altered pharmacokinetics (PK).
PK Profile Context: Immediate release (IR) formulation has a short duration of action (IV Bolus: 1 to 3 hours), indicating IR dosing is required to maintain steady concentrations if the SR effect is lost.
Recommendation for Tube Feeding: If administration via NG/PEG tube is unavoidable, split the dose to compensate for the loss of SR kinetics.
Suggested Dosing Adjustment: Change from 1 capsule once daily (QD) to:
Monitoring: Monitor patient’s heart rate and blood pressure closely following the change to split dosing.
[Pentop (pentoxifylline) tube feeding]
Medication: Pentop SR 400mg tablet (pentoxifylline)
Issue: Sustained-Release (SR) formulation is not designed for enteral tube administration and crushing will disrupt the controlled release mechanism.
PK Profile Context: - Short half-life: Parent drug (24-48 min); Active Metabolites (60-96 min). - Short half-life suggests that the SR mechanism is crucial for QD (once daily) dosing. - Time to peak is 2 to 4 hours, and onset of therapeutic action requires 2 to 4 weeks of multiple dosing.
Recommendation for Tube Feeding: If administration via NG/PEG tube is unavoidable, the daily dose must be split to compensate for the loss of SR kinetics and short half-life, ensuring stable concentrations.
Suggested Dosing Adjustment: Change from 1 tablet once daily (QD) to: - 0.33 tablet three times daily (TID) - OR 0.25 tablet four times daily (QID)
Monitoring: Monitor therapeutic response (e.g., pain, walking distance) and tolerability closely following dose splitting.
The patient is a 58-year-old male with diffuse large B-cell lymphoma (Lugano stage IV, non-GCB subtype) undergoing R-miniCHOP chemotherapy (most recent on 2025-04-15), with comorbidities of CKD stage IV, diabetic nephropathy, hypertension, ischemic heart disease, and history of recurrent ascites and pleural effusion. Currently, he presents with cellulitis of the left arm, progressive anemia, hypoalbuminemia, and fluctuating renal function. His vital signs remain stable but hypertensive (BP 176/84 mmHg on 2025-05-08). Blood glucose is moderately controlled. Ongoing management includes antibiotics, insulin, and supportive care for electrolyte and mineral balance.
Problem 1. Hematologic Abnormalities (Anemia and Leukocytosis)
Problem 2. Infection: Left Arm Cellulitis
Problem 3. CKD with Electrolyte and Mineral Imbalances
Problem 4. Hypertension and Cardiovascular Risk
Problem 5. Glycemic Control
This is a 58-year-old male with a history of diffuse large B-cell lymphoma (DLBCL, Lugano stage IV, non-GCB subtype) with peritoneal involvement, chronic kidney disease (CKD stage IV), nephrotic syndrome, type 2 diabetes mellitus (T2DM) with diabetic nephropathy, hypertension, and chronic ischemic heart disease. He has undergone multiple chemotherapy regimens, including R-miniCHOP (most recently on 2025-03-20). Recent trends show progressive anemia, CKD worsening, persistent electrolyte imbalances (mild hypokalemia), and fluctuating white blood cell counts with neutrophilic predominance. His blood pressure control is suboptimal, and he has ongoing pleural effusions. The disease burden includes lymphadenopathy, ascites, and ongoing metabolic derangements.
Problem 1. Hematologic Abnormalities (Anemia, Leukocyte Variability, Thrombocytopenia Trends)
Problem 2. Worsening Chronic Kidney Disease (CKD Stage IV)
Problem 3. Uncontrolled Hypertension
Problem 4. Persistent Pleural Effusion & Ascites
Final Remarks
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Patient]
The patient is a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (pT3cN0M0, FIGO stage IIIC, now stage IV with peritoneal carcinomatosis) post-debulking surgery (2023-04-20).
She is undergoing palliative chemotherapy with Q3W cycles of Avastin (bevacizumab) + Lipo-Dox (liposomal doxorubicin), now at C6 as of 2025-05-08.
Her disease remains radiographically stable per CT (2025-03-22), with chronic issues of anemia, hypomagnesemia, mild hypercalcemia, and cancer cachexia. Her general condition is ECOG 1, with stable vital signs and good tolerance of chemotherapy.
[Problems]
Problem 1. Recurrent Clear Cell Ovarian Carcinoma with Peritoneal Carcinomatosis
Problem 2. Anemia
Problem 3. Electrolyte Abnormalities: Hypercalcemia and Hypomagnesemia
Problem 4. Gastrointestinal Symptoms and Cachexia
Problem 5. Vital Signs and Port-A Status (not posted)
This is a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (Stage IIIC, FIGO IIIC; now clinically Stage IV since 2024-02) post-debulking surgery (2023-04-20), who has received multiple lines of chemotherapy, currently on C4 Bevacizumab (Avastin) + Liposomal Doxorubicin (Lipo-Dox) as of 2025-03-24.
Since the last review (2025-02-24), she experienced:
Problem 1. Recurrent Clear Cell Ovarian Carcinoma with Peritoneal Carcinomatosis
Problem 2. Anemia (Improved but Persistent)
Problem 3. Hypomagnesemia (Refractory)
Problem 4. Hypoalbuminemia and Cancer Cachexia
Problem 5. Hypercalcemia (Improved, now mild)
Problem 6. Hyponatremia (Chronic, mild) (not posted)
Problem 7. Vital Sign Instability: Tachycardia with Recent Improvement (not posted)
The patient, a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (pT3cN0M0, FIGO stage IIIC), is admitted on 2025-02-23 for C3 chemotherapy with Avastin (bevacizumab) + Lipo-dox (liposomal doxorubicin). She has progressive peritoneal carcinomatosis with massive ascites (CT 2024-12-12), hypercalcemia (Ca 3.07 mmol/L on 2025-02-23), and cachexia (weight loss of 5 kg over one month).
Key issues include:
Problem 1. Recurrent Ovarian Clear Cell Carcinoma with Progressive Disease
Problem 2. Hypercalcemia
Problem 3. Anemia and Thrombocytosis
Problem 4. Hyponatremia and Hypokalemia
Conclusion (not posted)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 63-year-old woman with nasopharyngeal carcinoma (NPC), cT1N1M0 stage II, who has completed definitive concurrent chemoradiotherapy (2024-12-25 to 2025-02-12) and is now undergoing adjuvant chemotherapy with the PF regimen (cisplatin + fluorouracil, started 2025-03-17). Recent clinical findings indicate stable disease with mild-to-moderate sensorineural hearing loss as a complication of treatment. Laboratory trends show gradually declining renal function and progressive anemia, now with moderate normocytic anemia. Liver function and electrolytes remain stable. Her overall physical condition is good (ECOG 1), with no major acute toxicity from chemotherapy noted. Vitals are stable.
Problem 1. Nasopharyngeal carcinoma, cT1N1M0, stage II, post CCRT and ongoing adjuvant PF chemotherapy
Objective
Diagnosed with NPC cT1N1M0 stage II by MRI (2024-11-22), biopsy confirmed non-keratinizing carcinoma (2024-11-28).
Received CCRT: cisplatin 40 mg/m² weekly from 2024-12-25 to 2025-02-12 plus radiotherapy 7000 cGy/35 fractions to primary and nodal areas.
Ongoing adjuvant chemotherapy with PF regimen started 2025-03-17 (cisplatin 80 mg/m² + 5-FU 1000 mg/m², using IBW due to obesity) with cycles on 2025-03-17 and 2025-04-08.
Recent nasopharyngoscopy (2025-03-12) shows much improvement with smaller tumor; PTA (2025-03-18) shows mild to moderately severe SNHL bilaterally.
Assessment
The patient’s treatment aligns with NCCN guidelines for stage II NPC (CCRT followed by adjuvant chemotherapy considered for bulky tumor).
Local disease appears well controlled with significant shrinkage; no new symptoms or evidence of recurrence.
Sensorineural hearing loss is a recognized side effect of cisplatin therapy, which is likely the cause of the hearing findings.
No major acute complications such as severe mucositis, infections, or disease progression noted.
Recommendation
Continue planned adjuvant PF chemotherapy as scheduled (next cycle 2025-05-08).
Schedule nasopharyngoscopy after completion of adjuvant chemotherapy to assess local disease.
Monitor hearing status periodically; consider dose adjustment if ototoxicity progresses.
Consider EBV DNA monitoring for long-term follow-up as a prognostic marker.
Problem 2. Renal function impairment (likely chemotherapy-related nephrotoxicity)
Objective
eGFR has declined from 84.25 mL/min/1.73m² (2025-03-04) to 47.31 mL/min/1.73m² (2025-05-07).
Creatinine increased from 0.74 mg/dL (2025-03-04) to 1.22 mg/dL (2025-05-07).
BUN rose from 19 mg/dL (2025-03-04) to 33 mg/dL (2025-05-07).
Cisplatin cycles administered, known nephrotoxic agent.
Assessment
The gradual deterioration of renal function is likely secondary to cisplatin nephrotoxicity.
Hydration protocols and Mg supplementation were provided (MgO and MgSO4), but the cumulative nephrotoxic effect is evident.
Current renal status is at CKD stage 3a (eGFR 47 mL/min/1.73m²), requiring close monitoring to avoid further decline.
Recommendation
Consider switching cisplatin to carboplatin for further cycles if renal function worsens or hits critical thresholds (eGFR <45 or creatinine >1.5 mg/dL).
Continue hydration and magnesium supplementation; monitor renal function before and after each chemotherapy cycle.
Regularly reassess electrolyte balance and urine output.
Problem 3. Anemia (progressive, moderate normocytic anemia)
Objective
HGB dropped from 12.2 g/dL (2025-02-11) to 7.8 g/dL (2025-05-07).
RBC decreased from 3.96 x10^6/uL (2025-02-11) to 2.26 x10^6/uL (2025-05-07).
MCV has remained normal (102.7 fL on 2025-05-07), indicating normocytic anemia.
PLT count has improved (207 x10^3/uL on 2025-05-07).
Assessment
The anemia is likely multifactorial: chemotherapy-induced myelosuppression, possible chronic disease-related anemia, and nutritional factors.
No evidence of hemolysis or bleeding was reported; reticulocyte count is not available but could help clarify marrow activity.
The anemia has progressed to a level requiring intervention (>8 g/dL down to 7.8 g/dL).
Recommendation
Consider red blood cell transfusion if symptomatic or if HGB drops below 7 g/dL.
Monitor CBC weekly during chemotherapy; if persistent, consider erythropoiesis-stimulating agents.
Evaluate iron, vitamin B12, folate, and reticulocyte count to exclude reversible causes.
Problem 4. Electrolyte and metabolic balance (not posted)
Objective
Sodium: stable at 135 mmol/L (2025-05-07) vs 138 mmol/L (2025-03-04).
Potassium: 4.2 mmol/L (2025-05-07) vs 3.8 mmol/L (2025-03-04), well maintained.
Magnesium: 1.7 mg/dL (2025-05-07) vs 1.3 mg/dL (2025-03-04), improved after supplementation.
Calcium: 2.51 mmol/L (2025-05-07), within normal range.
Assessment
Overall good control of electrolytes, likely due to ongoing MgO supplementation and hydration during chemotherapy.
No major disturbances noted; stable albumin (4.0 g/dL on 2025-05-07) supports normal total calcium.
Recommendation
Continue MgO 250 mg QID as prescribed; maintain hydration and regular monitoring.
Reassess electrolytes before and after chemotherapy cycles.
Monitor for signs of hypomagnesemia, especially due to ongoing cisplatin exposure.
Problem 5. Cardiovascular status (hypertension, cardiomegaly)
Objective
History of hypertension under medical control.
BP ranged 103/68 to 142/94 mmHg (2025-05-07), fluctuating but mostly acceptable.
CXR (2025-01-08) showed cardiomegaly, atherosclerotic changes.
No reported chest pain, dyspnea, or edema.
Assessment
Blood pressure control appears mostly stable but peaks up to 142/94 mmHg are noted, warranting observation.
No evidence of decompensated heart failure; no symptoms of ischemia.
Cardiomegaly and vascular changes are chronic and monitored.
Recommendation
Continue regular antihypertensive treatment; assess compliance.
Check BP routinely during chemotherapy, as fluid management can impact BP.
Consider follow-up echocardiography if any new cardiac symptoms arise.
[MedRec]
[Subjective]
cardiovascular status
gastrointestinal and hepatobiliary status
diabetes and metabolic status
[Objective]
vital signs and general
cardiovascular
hematology and labs
current medications
[Assessment]
post-NSTEMI secondary prevention
HCC and liver cirrhosis
anemia and thrombocytopenia
diabetes and metabolic management
[Plan / Recommendation]
post-NSTEMI secondary prevention
HCC and liver cirrhosis
anemia and hematology
diabetes and metabolic management
pharmacist interventions
[MedRec]
[consultation]
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
Patient: 56-year-old female
Diagnosis: Bilateral ovarian high-grade serous carcinoma (pT3cN0, FIGO
Stage IIIC), secondary malignant neoplasm of large intestine and rectum,
post-debulking surgery on 2025-01-10, currently receiving paclitaxel +
carboplatin chemotherapy
Reason for Visit: Follow-up on paclitaxel-related adverse reaction and
general treatment tolerance
S – Subjective
O – Objective
A – Assessment
P – Plan, Recommendation
The patient is a 56-year-old woman with bilateral ovarian high-grade serous carcinoma (pT3cN0, FIGO Stage IIIC) with known invasion to the sigmoid colon (pathology 2025-01-13), status post optimal debulking surgery on 2025-01-10, followed by chemotherapy with paclitaxel and carboplatin since 2025-03-07. She had a documented anaphylactic reaction to paclitaxel on 2025-03-06 but successfully rechallenged subsequently with enhanced premedication. She was admitted on 2025-05-05 for febrile episode with chills; initial CRP was elevated at 18.5 mg/dL (2025-05-04) despite normal urinalysis and negative COVID-19 and influenza screening. Blood cultures were pending, and broad-spectrum antibiotics Brosym (cefoperazone/sulbactam) were initiated. She remains afebrile on 2025-05-06 (36.2’C), hemodynamically stable (BP 109/65 mmHg), and has mild anemia (HGB 8.4 g/dL), normal neutrophil count (74.4%), elevated transaminases (ALT 124 U/L, AST 112 U/L), and rising CRP (18.2 mg/dL on 2025-05-05). Her overall clinical status appears stable but with concerns for persistent inflammation and potential hepatotoxicity.
Problem 1. Infection / Fever of Unknown Origin
Problem 2. Hepatic dysfunction
Problem 3. Anemia
Problem 4. Chemotherapy-induced peripheral neuropathy
Problem 5. Electrolyte balance (not posted)
[Management and Patient Education on Chemotherapy Agents for Paclitaxel-Related Adverse Reaction]
Bedside Visit: Today 2025-03-07, at approximately 14:00
During a bedside visit, the patient, along with her husband and two friends, was present. The patient stated that the symptoms experienced the previous day had completely resolved.
Incident Summary (2025-03-06):
Treatment Adjustment: Today, the attending physician reordered paclitaxel with modifications:
However, the infusion had not yet been administered as the patient had other scheduled examinations.
Patient Education:
[exam finding]
[MedRec]
[Subjective]
medication adherence and tolerability
- patient reported good medication adherence
- consistent with wife’s report: patient remains physically active (park
walking and slow jogging)
- no subjective complaints of adverse drug reactions since last pharmacy
consultation on 2024-12-19
- no signs of bleeding or bruising observed or reported
- denies hematuria, melena, or gingival bleeding
- skin ecchymosis (–), gum bleeding (–)
lifestyle and diet
- maintains regular physical activity (daily slow jogging, morning
walk)
- diet includes balanced intake: moderate vegetables, adequate protein,
low starch
- continues home use of avocado oil, low intake of cookies/bread
- adequate hydration and high fruit consumption reported
[Objective]
medication regimen (as of 2025-04-02)
- Bokey (Aspirin) 100 mg QD
- Brilinta (Ticagrelor) 90 mg BID
- Concor (Bisoprolol) 2.5 mg QD (half tab of 5 mg)
- Crestor (Rosuvastatin) 10 mg QD
- Ezetrol (Ezetimibe) 10 mg QD
vital signs and labs
- BP 119/76 mmHg, HR 72 bpm (2025-04-02)
- HbA1c 6.5% (2025-03-25)
- LDL-C 74 mg/dL, Cholesterol total 129 mg/dL, TG 102 mg/dL
(2025-03-25)
- Creatinine 0.85 mg/dL, eGFR 96.15 mL/min/1.73m² (2025-03-25)
- Platelet count 195 x10^3/uL, INR 0.98, APTT 24.5 sec (2025-01-19)
adverse drug reaction surveillance
- no signs of renal, hepatic, or hematological toxicity
- ALT 22 U/L (2025-03-25), BUN 21 mg/dL
[Assessment]
secondary prevention post-NSTEMI with triple-vessel CAD
- DAPT with Aspirin + Ticagrelor continued appropriately
- no bleeding complications reported
- lipid control goal met with LDL-C <70 mg/dL nearly achieved
- Crestor + Ezetrol combination appropriate for enhanced LDL
lowering
- heart rate and blood pressure well controlled under beta-blocker
therapy
- glycemic control acceptable (HbA1c 6.5%)
- renal function stable, no electrolyte imbalance
- good medication adherence, high motivation and physical
performance
[Plan / Recommendation]
continue current pharmacotherapy
- continue DAPT (Aspirin + Brilinta)
- monitor bleeding risk, especially with prolonged use
- continue statin + ezetimibe for aggressive lipid control
- continue bisoprolol for rate and cardiac remodeling control
monitoring
- follow-up labs in 3 months: lipid profile, HbA1c, renal and liver
panel
- ensure long-term safety of polypharmacy
- continue monitoring for bleeding signs (GI, urinary, skin)
- reinforce use of medication alert card for DAPT use, especially
pre-surgery
lifestyle and counseling
- reinforce regular exercise and hydration
- consider diabetes education session if glucose values begin trending
upward
- advise patient to consult before starting any over-the-counter
supplements
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 65-year-old female with high-grade serous carcinoma of the right ovary, FIGO Stage IIIB (pT3bN0 [if cM0]) diagnosed on 2024-12-27. She underwent optimal debulking surgery (R0 resection), followed by adjuvant chemotherapy with paclitaxel plus carboplatin Q3W, initiated on 2025-02-09. Tumor markers, especially CA-125, have declined rapidly and are now within normal limits (CA-125 4.73 U/mL on 2025-04-18), with no radiologic evidence of residual or recurrent tumor (Gynecologic sonography 2025-04-26). Recent labs show hematologic nadirs with recovery, preserved renal and liver function, and stable nutritional and electrolyte status. The current clinical status is consistent with an ongoing treatment response without relapse.
Problem 1. Ovarian Serous Carcinoma, FIGO IIIB, Post Debulking + Chemo (C4)
Problem 2. Hematologic Suppression and Recovery During Chemotherapy
Problem 3. Renal, Hepatic, and Electrolyte Status
The patient is a 65-year-old female with right ovarian high-grade serous carcinoma (HGSOC), diagnosed as pStage IIIB (pT3bN0 [if cM0]) following debulking surgery on 2024-12-27. She recently began chemotherapy with Taxol (paclitaxel) plus Carboplatin on 2025-02-09 (C1D1, Q3W). Her postoperative recovery has been uneventful, and she has a Port-A for chemotherapy administration. The pathology indicated metastatic disease involving the peritoneum, omentum, and rectal surface but no lymph node involvement. Her ECOG performance status is 0, with manageable symptoms. Current problems include the malignancy, potential insomnia, and an upper lip herpes lesion.
Problem 1. Right Ovarian Cancer (HGSOC, FIGO Stage IIIB, Post-Surgery)
Problem 2. Insomnia
Problem 3. Herpes Lesion on Upper Lip
Problem 4. Postoperative Follow-Up and Monitoring
[MedRec]
[surgical operation]
[Subjective]
medication adherence and concerns - patient reported consistent use of prescribed medications - includes insulin (Apidra and Toujeo), antihypertensives, lipid-lowering agents, thyroid hormone, and antibiotics - patient stated that home blood pressure readings have recently become more unstable - plans to document these readings and discuss with Cardiac Surgeon Dr. Xu at the next follow-up in May 2025 - erythropoietin therapy is administered during dialysis sessions on Thursdays - dialysis team determines need for dosing based on lab monitoring
glycemic and wound-related feedback - patient reported that post-cardiac surgery, home-measured blood glucose levels have been more stable compared to earlier periods - no current complaint of wound-related symptoms following the 2025-04-09 sternal debridement and closure
[Objective]
medication list and pharmacologic therapy - cardiovascular - Blopress (candesartan), Nebilet (nebivolol), Caduet (amlodipine/atorvastatin), Plavix FC (clopidogrel), Bokey (aspirin) - antidiabetics - Apidra (insulin glulisine), Toujeo (insulin glargine), Ozempic (semaglutide) - endocrine - Eltroxin (levothyroxine) 3# QW12345 + 4# QW67 - infection - Curam (amoxicillin/clavulanic acid) 1# QD 8D (completed) - analgesics and others - Acetal (acetaminophen), Pentop (pentoxifylline), Takepron (lansoprazole), Through (sennoside), Tramacet (tramadol/acetaminophen)
laboratory monitoring - renal: creatinine 6.19 mg/dL, eGFR 7.44 mL/min/1.73m² (2025-04-07) - thyroid: TSH 1.090 uIU/mL, Free T4 1.300 ng/dL (2025-04-18) - glycemic: HbA1c 7.9% (2025-03-11); patient-reported trend improving - hematology: HGB persistently low (8.4 g/dL on 2025-04-17), ferritin 525.8 ng/mL (2025-03-07) - inflammatory: CRP improved (2.3 mg/dL on 2025-03-06)
[Assessment]
multimorbidity pharmacotherapy - polypharmacy regimen aligned with ESRD, post-CABG, T2DM, and hypothyroidism - thyroid replacement is biochemically sufficient - renal dosing consideration appropriate - erythropoietin support administered as needed during dialysis, likely explaining absence of documented ESA prescription - persistent anemia with HGB < 9 g/dL likely chronic and multifactorial
blood pressure instability - patient-reported instability in home BP readings may reflect evolving post-CABG hemodynamic adaptation - multiple antihypertensives in use; potential for optimization pending cardiology input
diabetes therapy - combination of basal-bolus insulin with GLP-1 agonist may be intensive in ESRD - HbA1c suboptimal but trending better per patient - risk-benefit balance needs review especially if glycemic lability recurs
wound infection management - sternal wound debridement and primary closure performed on 2025-04-09 - completed 8-day Curam course; no signs of recurrence reported
[Plan / Recommendation]
hypertension follow-up - encourage continued home BP recording - bring complete log to 2025-05 visit with Dr. Xu for possible antihypertensive regimen adjustment - review for possible postural changes or dialysis-related fluctuations
anemia and ESA optimization - continue monitoring via dialysis center with Thursday lab checks - recommend coordination between nephrology and pharmacy if additional support needed - consider rechecking iron panel in Q2 2025
diabetes management - current regimen appears adequate with patient-reported glucose stabilization - evaluate hypoglycemia risk and A1c trend at next endocrinology visit - consider CGM if hypoglycemia unawareness is suspected
medication reconciliation and review - continue current polypharmacy plan; no immediate duplication or interaction flagged - reassess need for Pentop vs GI prophylaxis (Takepron) if symptom-free - maintain thyroid hormone dosing; repeat TFT in ~3 months
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This 77-year-old woman with stage IIIB adenocarcinoma of the proximal transverse colon (pT4aN1b, G2, LVI+, PNI+, CRM+), status post right hemicolectomy (2024-05-16), has demonstrated peritoneal recurrence with progression to carcinomatosis and liver/lung metastases (CT 2025-03-13). After an initial FOLFOX course, chemotherapy was shifted to FOLFIRI plus Avastin (bevacizumab) from 2024-09-26 to 2025-03-10. Currently admitted for ascites and symptomatic hyponatremia (Na 116 mmol/L on 2025-04-29), she shows signs of persistent inflammation, hypoalbuminemia, normocytic anemia, and poorly controlled hyperglycemia, raising concern for further cancer progression, possible infection, and nutritional compromise.
Problem 1. Peritoneal carcinomatosis and metastatic colon adenocarcinoma
Problem 2. Hyponatremia
Problem 3. Anemia and leukocytosis
Problem 4. Hyperglycemia
Problem 5. Hypoalbuminemia and nutritional compromise
[CEA and CA199 doubling: consider updating imaging]
Hyponatremia and hypomagnesemia were observed and appropriately supplemented.
The patient has received 3 sessions of FOLFOX (with 80% oxaliplatin dose) at approximately 28-day intervals, with the last session on 2024-08-22. The eGFR has remained around 70 ml/min/1.73m² over the past few months, so no dose adjustment is needed.
Notably, both CEA and CA199 markers have doubled in the past month, suggesting that updating imaging may be necessary to assess disease progression.
2024-08-13 CEA (NM) 7.470 ng/ml
2024-07-09 CEA (NM) 2.764 ng/ml
2024-06-14 CEA (NM) 4.450 ng/ml
2024-04-27 CEA 118.16 ng/ml
2024-08-13 CA-199 (NM) 53.183 U/ml
2024-07-09 CA-199 (NM) 24.645 U/ml
2024-06-14 CA-199 (NM) 46.408 U/ml
[MedRec]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
The patient is a 67-year-old male with metastatic adenocarcinoma of the ascending colon (pT3N0M1b, stage IVB, dMMR with BRAF V600E mutation) status post right hemicolectomy (2024-10-30) and ongoing systemic chemotherapy with A-FOLFIRI + bevacizumab since late 2024. PET (2025-04-21) and chest CT (2025-03-05) show no new evidence of disease progression, with stable small lung metastases and no FDG-avid lung nodules. CEA levels have remained stable. He has experienced intermittent chemotherapy-induced neutropenia and anemia but remains functionally compensated with stable renal and hepatic functions (labs 2025-04-25). Blood pressure remains suboptimally controlled despite dual antihypertensive therapy. Currently, no critical organ dysfunction is observed, but vigilant monitoring is still necessary.
Problem 1. Metastatic Colorectal Cancer - Treatment Response and Disease Status
Problem 2. Chemotherapy-Induced Anemia and Hematologic Status
Problem 3. Hypertension and Cardiovascular Risk under Antiangiogenic Therapy
Would you like me to also draft a structured progress note (“POMR
style”) summarizing this into a clinical document?
It might help if you are preparing a report or simulated case file!
The patient, a 67-year-old male with metastatic adenocarcinoma of the ascending colon (pT3N0M1b, stage IVB, dMMR) with lung metastases, is undergoing systemic chemotherapy with A-FOLFIRI. Since the last review on 2024-12-23, his treatment course has continued with some modifications in irinotecan dosing, and updated imaging and laboratory findings provide a more comprehensive view of his current status. Additional concerns include cardiovascular monitoring, persistent mild anemia, and treatment-related toxicities.
Problem 1: Metastatic Colorectal Cancer - Disease Status & Treatment Response
Problem 2: Chemotherapy-Induced Anemia & Hematologic Trends
Problem 3: Cardiovascular Risk & Blood Pressure Management
Medication Review (not posted)
| Medication | Indication | Appropriateness | Concerns/Adjustments |
|---|---|---|---|
| A-FOLFIRI | Metastatic CRC | Standard per guidelines | Ongoing irinotecan dose adjustment needed. Monitor for toxicity. |
| Amtrel (amlodipine/benazepril) 5/10 mg QD | Hypertension | Partially effective | Consider dose increase or alternative/additional antihypertensive. |
| Apolin (hydralazine) 25 mg PRN Q12H | BP control | Inconsistent efficacy | Switch to scheduled dosing if needed. |
| Promeran (metoclopramide) 3.84 mg TIDAC | Nausea/Vomiting | Appropriate | Monitor for tardive dyskinesia with prolonged use. |
| Pariet (rabeprazole) 20 mg QD | GERD | Appropriate | Long-term use should be reviewed periodically. |
| B-Complex (B1, B2, B6, nicotinamide) 1 mL IV QD | Nutritional support | Appropriate | No significant concerns. |
| Metoclopramide 10 mg/2 mL IV PRN Q6H | Breakthrough nausea | Appropriate | PRN use limits risk of extrapyramidal symptoms. |
[Key Summary]
The patient, a 67-year-old male, has adenocarcinoma of the ascending colon with lung metastasis (pT3N0M1b, stage IVB) and is mismatch repair deficient (dMMR). He has a history of right hemicolectomy on 2024-10-30 and port-A implantation on 2024-11-20. Recent chemotherapy with A-FOLFIRI and bevacizumab (2024-12-20) was initiated, with a 20% dose reduction for irinotecan due to toxicity concerns. Imaging findings confirm bilateral lung metastases, consolidation, and hepatic vascular blushes. He also has hypertensive heart disease, gastroesophageal reflux disease (GERD), and a past surgical history of cholecystectomy (2018-10-23).
Laboratory values on 2024-12-20 showed no significant hepatic or renal impairment (eGFR 84.05 mL/min/1.73m², AST 18 U/L, ALT 20 U/L). However, a mild anemia persists (HGB 10.5 g/dL), and thrombocytosis (PLT 500 × 10³/uL) may indicate systemic inflammation or a paraneoplastic process.
[Problem-Oriented Comments]
[Medication Review]
[lab data]
2025-04-15 CEA (NM) 2.900 ng/ml
2025-03-14 CEA (NM) 3.940 ng/ml
2025-02-13 CEA (NM) 6.700 ng/ml
2025-01-16 CEA (NM) 5.550 ng/ml
2024-12-25 CEA (NM) 4.180 ng/ml
2024-11-28 CEA (NM) 2.750 ng/ml
2024-10-30 CEA (NM) 1.880 ng/ml
2024-10-04 CEA (NM) 3.175 ng/ml
2024-09-03 CEA (NM) 3.382 ng/ml
2024-08-13 CEA (NM) 2.183 ng/ml
2024-07-16 CEA (NM) 2.372 ng/ml
2024-06-25 CEA (NM) 1.939 ng/ml
2024-06-04 CEA (NM) 1.690 ng/ml
2024-05-07 CEA (NM) 1.649 ng/ml
2024-04-17 CEA (NM) 1.597 ng/ml
2024-03-12 CEA (NM) 2.682 ng/ml
2024-02-20 CEA (NM) 2.331 ng/ml
2024-01-30 CEA (NM) 1.980 ng/ml
2024-01-17 CEA (NM) 3.715 ng/ml
2024-01-03 CEA (NM) 3.334 ng/ml
2023-12-07 CEA 3.00 ng/mL
2023-11-10 CEA 3.03 ng/mL
2023-10-12 CEA 4.25 ng/mL
2023-07-25 CEA 2.31 ng/mL
2023-09-20 HBsAg (NM) Negative
2023-09-20 HBsAg Value (NM) 0.422
2023-09-20 Anti-HBc (NM) Positive
2023-09-20 Anti-HBc Value (NM) 0.01
2023-09-20 Anti-HCV (NM) Negative
2023-09-20 Anti-HCV Value (NM) 0.042
2023-09-20 Anti-HBs (NM) Positive
2023-09-20 Anti-HBs value (NM) 46.4 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
PharmaCloud data indicates that the patient has only been to our hospital within the last three months. Our urologist prescribed a refill of Harnalidge (tamsulosin) on 2023-09-26, and the medication is currently being used without any issues.
[MedRec]
[exam finding]
[MedRec]
[chemotherapy]
[exam finding]
[chemotherapy]
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
This is an 82-year-old male with acute myeloid leukemia (AML) diagnosed on 2025-03-18, complicated by pancytopenia, hemodialysis-dependent ESRD, HCAP, and multiple AV shunt interventions. He has had multiple episodes of anemia and thrombocytopenia requiring transfusions, and has received low-dose cytarabine (2025-03-25 to 2025-03-27). Despite ongoing infection control with various antibiotics, his condition is complicated by severe malnutrition, hypoalbuminemia, and suspected lower extremity soft tissue infection. He is now on enteral tube feeding and a DNR/comfort care pathway has been signed (2025-04-02).
Problem 1. Acute Myeloid Leukemia
Problem 2. Infection (HCAP, Fungal Risk)
Problem 3. ESRD with AV Shunt Complications
Problem 4. Hematologic Support (Anemia and Thrombocytopenia)
Problem 5. Nutritional Insufficiency and GI Support (not posted)
Problem 6. Cardiopulmonary Status and Hemodynamics
[Posanol (posaconazole) tube feeding]
Posanol (posaconazole) suspension form is not available in this hospital. Since the Posanol (posaconazole) tablet package insert does not explicitly specify it as a delayed-release tablet, it is recommended that if the medication needs to be administered via tube feeding, the simple suspension method might be used. Additionally, please also adjust the dosing from the original 3# QD to 1# TID.
This is an 82-year-old male with a complex medical history including acute myeloid leukemia (AML, newly diagnosed on 2025-03-18), end-stage renal disease (ESRD) on hemodialysis, type 2 diabetes mellitus, atrial fibrillation with pacemaker, and prior AV shunt interventions. He was admitted on 2025-03-21 for fever and abdominal pain, with CXR showing bilateral pulmonary infiltrates and clinical suspicion of pneumonia. He received Tapimycin (piperacillin/tazobactam) and later low-dose cytarabine (AraC) SC from 2025-03-24 for AML. He remains hemodynamically stable but has ongoing pancytopenia, elevated inflammatory markers, and poor oral intake.
Problem 1. Acute Myeloid Leukemia (newly diagnosed)
Problem 2. ESRD with metabolic complications
Problem 3. Infection – Suspected pneumonia
Problem 4. Invasive fungal infection – Suspected
Problem 5. Nutritional insufficiency
Problem 6. Type 2 Diabetes Mellitus
Problem 7. Cardiovascular disease (AF + Heart failure)
[exam finding]
[MedRec]
[immunochemotherapy]
[exam finding]
[MedRec]
[chemotherapy]
This 64-year-old woman with right triple-negative breast cancer (ER 0%, PR 0%, HER2 0%, Ki-67 75%) underwent partial mastectomy with axillary dissection (ypT2N2M1, stage IV) and has experienced widespread metastases (lung, liver, bone, lymph nodes) since 2024-12-23 (CT 2024-12-23, PET 2024-12-27). She is on 3rd-line palliative chemotherapy with weekly Paclitaxel since 2025-03-11 after prior treatment with EC x4, discontinued Taxotere due to ILD, surgery, and Halaven x7. She has anemia, persistent leukopenia, transient CRP elevation, and evidence of metastatic bone pain and neurologic symptoms (CT 2025-04-15, Bone scan 2025-03-26, NCV 2025-03-11). Renal and hepatic functions remain stable. Imaging (CT 2025-04-15) now shows C5 bone destruction. Her interstitial lung disease is stable. Overall, disease remains active and symptomatic, warranting close monitoring and possible regimen reevaluation.
Problem 1. Disease Progression in Triple-Negative Breast Cancer (TNBC)
Problem 2. Hematological Suppression (Neutropenia and Anemia)
Problem 3. Renal and Hepatic Function (not posted)
Problem 4. Urinary Tract Inflammation (Resolved) (not posted)
Problem 5. Bone Metastasis with Neurological Implication
[MedRec]
[Subjective]
medication adherence and symptom status - patient reported no current chest discomfort, dyspnea, or palpitations - noted improved exercise tolerance since discharge - denies dizziness or lightheadedness - bowel habit regular with current use of Through (sennoside) - no abdominal discomfort or constipation - medication adherence high - takes all prescribed medications as instructed, aware of PRN Uretropic (furosemide) threshold - no missed doses or adverse effects reported
[Objective]
cardiovascular medication - Bokey (aspirin), Brilinta (ticagrelor): dual antiplatelet therapy continued appropriately post-PCI - Concor (bisoprolol): low dose (1.25 mg) maintained with hold instructions if HR < 60 or SBP < 90 - Crestor (rosuvastatin): lipid-lowering for secondary prevention - Cordarone (amiodarone): low-dose for rhythm control in paroxysmal AF - Ivabradine: initiated during admission, not included in discharge list - stopped
heart failure therapy - Jardiance (empagliflozin): continued for HFmrEF with preserved renal function (eGFR 97.17 on 2025-04-14) - Uretropic (furosemide): 0.5# PRN if BW > 63 kg, appropriate for volume control post-decompensation - Nexium (esomeprazole): gastroprotection due to DAPT - Through (sennoside): regularized bowel movement support
labs and trends - renal function stable and improved (eGFR 84.3 → 97.17 mL/min/1.73m² from 2025-04-09 to 2025-04-14) - electrolytes WNL (Na 138, K 3.7 mmol/L on 2025-04-14) - NT-proBNP initially elevated (4737 pg/mL on 2025-04-05) - hs-Troponin I peaked (10026.8 pg/mL on 2025-04-05), trending down
[Assessment]
post-MI secondary prevention - current pharmacotherapy aligns with ACC/AHA guidelines - DAPT, beta-blocker, statin, SGLT2i all present - Cordarone for rhythm control reasonable short term; monitor thyroid/hepatic profiles
heart failure optimization - heart failure regimen includes beta-blocker, SGLT2i, diuretic (PRN), and patient education - symptoms stable and improving - patient engaged with cardiopulmonary rehab
medication safety and interactions - drug duplication or interactions not identified - Cordarone and Brilinta interaction (increased bleeding risk) noted but monitored - QT prolongation risk with Cordarone—ECG monitoring should be ensured - renal and electrolyte status favorable; diuretic strategy well individualized
[Plan / Recommendation]
support safe medication use and monitoring - reinforce indication and adherence to Bokey, Brilinta, Concor, and Jardiance - provide education on bleeding signs, orthostasis, hypoglycemia, and dehydration - recommend lab follow-up: - renal/electrolyte panel in 1–2 weeks - TSH, LFTs, ECG within 4–6 weeks for Cordarone safety monitoring
optimize heart failure outcomes - emphasize continued self-monitoring (weight, symptoms, BP/HR) - educate on PRN Uretropic use based on daily weight - encourage compliance with rehab and gradual activity increase
ensure long-term cardiovascular protection - encourage lipid panel recheck and HbA1c reassessment in 3 months - assess if further intensification (e.g., addition of ACEi/ARB or Vericiguat) needed - promote lifestyle changes: low-sodium diet, smoking cessation if applicable, routine exercise
[lab data]
2025-02-26 CD45+Total leukocyte 341547 /uL
2025-02-26 %CD34+ 2.23 %
2025-02-26 CD34+ Count 7600 /uL
2025-02-26 CD45+Total leukocyte 9806 /uL
2025-02-26 %CD34+ 2.07 %
2025-02-26 CD34+ Count 203 /uL
2025-02-25 CD45+Total leukocyte 122264 /uL
2025-02-25 %CD34+ 2.08 %
2025-02-25 CD34+ Count 2542 /uL
2025-02-25 CD45+Total leukocyte 3000 /uL
2025-02-25 %CD34+ 1.55 %
2025-02-25 CD34+ Count 46 /uL
2025-02-12 RPR Nonreactive
2025-02-12 β-HCG 1.8 mIU/mL
2025-02-12 HIV Ab-EIA Nonreactive
2025-02-12 Anti-HIV Value 0.06 S/CO
2025-02-12 Anti HTLV I/II Nonreactive
2025-02-12 Anti HTLV I/II Value 0.09 S/CO
2025-02-12 CMV IgM Nonreactive
2025-02-12 CMV IgM Value 0.05 Index
2025-02-12 CMV_IgG Reactive
2025-02-12 CMV_IgG Value 172.2 AU/mL
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
Problem 1. Relapsed Diffuse Large B-Cell Lymphoma (DLBCL), non-GCB, Double Expressor
Problem 2. Bone Marrow Suppression & Hematologic Recovery Post-Chemotherapy
Problem 3. Infection Risk and Antimicrobial Prophylaxis
Problem 4. Glycemic Control and Diabetes Management
Problem 5. Electrolyte Management (Focus on Magnesium)
Problem 6. Cardiovascular Monitoring
[Patient Summary]
Th e patient, a 67-year-old female with a history of diffuse large B-cell lymphoma (DLBCL), diabetes mellitus (DM), and hypertensive heart disease, has experienced recurrent lymphoma involving the left breast and axillary lymph nodes as of 2024-07-31.
She is currently undergoing chemotherapy with R-GemOx (rituximab, gemcitabine, and oxaliplatin) for relapsed DLBCL, with stable general condition but persistent disease activity in imaging studies (CT, PET).
Notable findings include historical impaired left ventricular relaxation (2024-08-23), evidence of glucose hypermetabolism in PET (2024-08-08), and mild hyperglycemia with suboptimal glycemic control. There is no significant bone marrow involvement per biopsy on 2024-08-22.
The patient exhibits anemia with a downward trend in hemoglobin, potentially chemotherapy-related thrombocytosis (2025-01-05), and recent glucose elevation requiring titration of insulin (2025-01-06). Despite a history of aggressive lymphoma treatment since 2018, recurrent disease has impacted prognosis and necessitated ongoing management.
[Problem Comments]
Problem 1: Relapsed Diffuse Large B-Cell Lymphoma (DLBCL)
Problem 2: Suboptimal Glycemic Control
Problem 3: Impaired Cardiac Function
Problem 4: Chemotherapy-Induced Anemia and Thrombocytosis
Problem 5: History of Multinodular Goiter and Thyroid Nodules
[MedRec]
[Subjective]
The daughter came to consult on behalf of her mother (the patient).
anticoagulant medication education - patient was prescribed Lixiana (edoxaban 30mg) QD starting 2025-04-23 for stroke control/prevention in atrial fibrillation - explained that patient has AF (SOAP 2025-04-21), prior old infarcts (CT 2025-04-22), and risk of thromboembolism
bowel habit and diet - patient experiences chronic constipation - currently induces diarrhea every other day by drinking milk - has tried over-the-counter probiotics but without benefit - daily vegetable and fruit intake is low - aware of need for more fiber but no consistent dietary adjustment yet
[Objective]
brain imaging - CT (2025-04-22): large calcified meningioma (5.4cm) compressing right cerebellum; smaller frontal lesion with edema; old infarcts in bilateral cerebral lobes
current medication - Lixiana (edoxaban 30mg) QD x14 days - also on Uretropic (furosemide), Const-K ER (potassium chloride), Cordarone (amiodarone), and Eltroxin (levothyroxine), among others (SOAP 2025-04-21)
labs and renal function - eGFR 65.77 mL/min/1.73m² (2024-12-24), supports Lixiana standard dosing - PLT 154 x10³/uL, INR 1.08 (2024-12-22), no bleeding diathesis noted
[Assessment]
edoxaban initiation justified - AF, history of stroke, and CHA₂DS₂-VASc ≥2 support anticoagulation - Lixiana (edoxaban) 30mg QD appropriate considering renal function and bleeding risk
patient lacks understanding of constipation management - laxative misuse (inducing diarrhea with milk) may impact bowel regularity and nutrient absorption - low fiber intake likely contributes to constipation and may limit gut flora balance despite probiotic use
[Plan / Recommendation]
reinforce Lixiana (edoxaban) education and precautions - remind patient to take Lixiana at the same time daily, with or without food - avoid double dosing if missed; skip if not within 12 hours - advise on bleeding signs: unexplained bruising, blood in stool/urine, prolonged bleeding - caution about concurrent use of NSAIDs or antiplatelets
support bowel health via diet - recommend increasing fiber-rich vegetables and fruits gradually - promote natural prebiotic effect of fiber to support probiotic flora - discourage self-induced diarrhea as a means of managing constipation - consider fiber supplements or safer laxative alternatives under physician guidance
monitor adherence and bleeding - follow-up in 1–2 weeks for tolerability and side effects - consider referral to dietitian if bowel habits remain poorly controlled despite fiber advice
[MedRec]
[MedRec]
[Subjective]
- 2025-04-23 telephone follow-up attempted with patient; no one answered
at residence. Contact was established with the patient’s son.
- The son reported that a friend had recently recommended Coenzyme Q10,
asking whether it was beneficial, and also expressed concerns regarding
the high cost of such health supplements.
- The patient has not been fully adherent to prescribed DOAC therapy,
citing irregular intake.
[Objective]
- The patient is status post DES placement in LAD on 2025-03-22, with a
diagnosis of NSTEMI, paroxysmal atrial fibrillation, and SSS with
pacemaker (POMR 2025-03-19 to 2025-03-25).
- Current anticoagulation: Lixiana FC (edoxaban 30mg QD).
- As of 2025-04-09, poor adherence to DOAC noted in cardiology
outpatient documentation.
- No documented allergy to Coenzyme Q10 or drug-nutrient interaction
alerts in current medication regimen.
[Assessment]
- Medication adherence: Nonadherence to DOAC post-DES raises concern for
stent thrombosis or stroke risk in the setting of atrial
fibrillation.
- CoQ10 inquiry: There is no contraindication to concomitant use of
CoQ10 and edoxaban. However, there is no strong evidence of
cardiovascular benefit in this context, and the high cost may pose an
unnecessary financial burden.
- Education gap: Family may not fully understand the critical importance
of uninterrupted anticoagulation following coronary stent placement.
[Plan]
- Re-emphasized to the son the lifesaving necessity of strict adherence
to DOAC therapy, especially after DES implantation and in atrial
fibrillation.
- Advised that Coenzyme Q10 is not contraindicated but not essential,
and benefits remain unproven for this indication; high cost should be
considered before purchase.
- Suggested in-person consultation or home visit if nonadherence
continues.
- Will reattempt direct phone contact with the patient to reinforce
counseling.
- Documented counseling and will update cardiology team during next
scheduled case review.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Problem 1. Bone marrow suppression after chemotherapy
Problem 2. Renal and hepatic function monitoring during chemotherapy
Problem 3. Chemotherapy adverse effect management (supportive care) (not posted)
Problem 4. Electrolyte balance (not posted)
Problem 5. Surveillance of NPC recurrence
This is a 64-year-old male with a history of nasopharyngeal carcinoma (NPC), nonkeratinizing undifferentiated type, initially stage II, treated with adjuvant chemoradiotherapy >10 years ago, though treatment was incomplete. He experienced local recurrence in the left neck and underwent modified radical neck dissection on 2024-10-07, revealing rypT0N1 disease with extranodal extension (+). He subsequently completed concurrent chemoradiotherapy (2024-11-29 to 2025-01-14) and is now undergoing adjuvant chemotherapy with PF3 regimen, with two cycles completed as of 2025-03-27.
Laboratory results suggest stable renal and liver function, mild post-chemotherapy leukopenia, and preserved hematologic and electrolyte profiles. Imaging and endoscopy show no overt recurrence in the nasopharynx, with prior FDG-PET-avid cervical node proven malignant (surgically resected).
Problem 1. Locoregional recurrence of nasopharyngeal carcinoma (NPC), status post multimodal therapy
Problem 2. Bone marrow suppression (post-chemotherapy leukopenia)
Problem 3. Renal and hepatic function during chemotherapy
Problem 4. History of traumatic thoracic injury (rib fractures and lung wedge resection)
[MedRec]
[radiotherapy]
[immunochemotherapy]
2024-05-29 - enfortumab vedotin 30mg NS 100mL 1hr
2024-05-22 - enfortumab vedotin 30mg NS 100mL 1hr
2024-05-02 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-04-22 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
2024-03-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-03-06 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-02-21 - gemcitabine 1000mg/m2 1000mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-01-24 - gemcitabine 1000mg/m2 1000mg NS 100mL 30min + cisplatin 70mg/m2 80mg NS 500mL 3hr
2024-01-11 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 80mg NS 500mL 3hr + furosemide 20mg
2022-07-27 - cisplatin 30mg/m2 30mg BI 1hr
2022-07-13 - mitomycin-C 30mg/m2 30mg BI 1hr
2022-07-06 - cisplatin 30mg/m2 30mg BI 1hr
2022-06-08 - cisplatin 30mg/m2 30mg BI 1hr
2022-06-01 - cisplatin 30mg/m2 30mg BI 1hr
2022-05-25 - cisplatin 30mg/m2 30mg BI 1hr
2022-05-18 - cisplatin 30mg/m2 30mg BI 1hr
2022-05-06 - mitomycin-C 30mg/m2 30mg BI 1hr
2021-09-15 - mitomycin-C 30mg/m2 30mg BI 1hr
2021-09-08 - cisplatin 30mg/m2 30mg BI 1hr
2021-09-01 - cisplatin 30mg/m2 30mg BI 1hr
2021-08-25 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-08-18 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-08-11 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-08-06 - mitomycin-C 30mg/m2 30mg BI 1hr
2021-04-07 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-31 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-24 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-17 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-10 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-03 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-02-24 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-02-05 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-10-31 - cisplatin 30mg/m2 30mg BI 1hr
2020-10-07 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-30 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-23 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-16 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-09 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-02 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-07-22 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-07-03 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 100mg NS 500mL 3hr + furosemide 20mg
2020-05-06 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-04-29 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 100mg NS 500mL 3hr + furosemide 20mg
2020-03-25 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-03-04 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-02-21 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 100mg NS 500mL 3hr + furosemide 20mg
2020-02-12 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-01-22 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-01-08 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Dulcolax (bisacodyl 5mg) tube feeding]
Due to the enteric coating of Dulcolax (bisacodyl 5mg) tablets, splitting or crushing them is not recommended. As an alternative, Bisadyl (bisacodyl 10mg) suppositories, which contain the same active ingredient, can be utilized. Currently, the patient is taking Through (sennoside 12mg) twice daily at bedtime and Bisadyl (bisacodyl 10mg) suppositories 2 units rectally as needed once daily.
[Problem List]
Problem 1. Esophageal Squamous Cell Carcinoma (Post-CCRT, ongoing monitoring)
Problem 2. Hematological Status (Post-CCRT myelosuppression and recovery) (below not posted)
Problem 3. Renal and Hepatic Function (Monitoring cisplatin-related toxicity)
Problem 4. Electrolyte and Metabolic Status (Post-treatment stability)
Problem 5. Nutritional Status and Gastrointestinal Support (During recovery phase)
Problem 6. Auditory Status (Baseline hearing assessment)
Problem 7. Severe Anorexia and Weight Loss (Loss of appetite - Grade 3) (posted)
The patient is a 62-year-old male with esophageal squamous cell carcinoma (ESCC), cT3N2M0, Stage III (Pathology 2025-02-12; EGD 2025-02-12; CT 2025-02-22; EUS 2025-02-26), currently arranged concurrent chemoradiotherapy (CCRT) with cisplatin and fluorouracil (2025-03-17). No distant metastasis was identified in PET (2025-02-24). The tumor is locally advanced, involving lymph nodes (subcarinal, paraesophageal region) but remains resectable possibility.
Additional relevant conditions include:
- Atrophic gastritis with gastric polyps (EUS 2025-02-26)
- Mild to moderate emphysematous changes in both lungs (CT
2025-02-22)
- Arachnoid cyst (62mm) in the right retro-cerebellar region (MRI
2025-03-01)
- Hyperplastic colorectal polyps (Pathology 2025-02-26)
- Degenerative joint disease with increased bone scan uptake in multiple
sites (Bone scan 2025-02-27)
- Mild anemia (HGB 13.4 g/dL) and stable renal function (eGFR 127.75
mL/min/1.73m²) (Labs 2025-03-17)
- Good nutritional status but with increased caloric and protein
requirements (Nutrition 2025-03-17)
Problem 1. Esophageal Squamous Cell Carcinoma (cT3N2M0, Stage III, arranged CCRT)
Problem 2. Nutritional Status (Increased Caloric and Protein Requirement During CCRT)
Problem 3. Hematologic and Organ Function Monitoring (During Chemoradiation Therapy)
Problem 4. Pulmonary Function (Mild Emphysematous Change, Smoking History)
Problem 5. Skeletal and Neurologic Considerations (Bone Scan Uptake, Arachnoid Cyst) (not posted)
Overall Plan
[exam finding]
[MedRec]
[consultation]
[Subjective]
chest pain with dyspnea on 2025-03-26
- presented to ER due to new-onset chest pain without radiation
- described onset around 05:00, no associated back pain (POMR
2025-03-27)
- denied further episodes of chest pain or dyspnea post-intervention
(POMR 2025-03-28)
- on 2025-04-16, during pharmacist contact, the patient reported no
current respiratory discomfort, noted that urine had changed from yellow
to clear, and stated that he could walk briskly without problems
history of cardiovascular and metabolic diseases
- known hypertension, diabetes mellitus, mixed hyperlipidemia
- regular follow-up at NTU hospital (POMR 2025-03-27)
post-discharge condition
- clinically stable post-PCI (SOAP 2025-03-31)
- no recurrent chest discomfort reported
- instructed to monitor symptoms and follow up in outpatient
department
- pharmacist reminded the patient on 2025-04-16 to seek medical
attention promptly if any signs of bleeding occur due to use of dual
antiplatelet therapy
[Objective]
acute coronary syndrome and cardiac markers
- markedly elevated hs-Troponin I: 12.4 → 199.3 → 497.4 → 1284.6 pg/mL
(Labs 2025-03-26 to 2025-03-28)
- CKMB: 1.4 → 3.3 → 4.5 → 8.3 ng/mL, CK: within normal range (Labs
2025-03-26 to 2025-03-28)
- 2D echo showed LVEF 58% with no RWMA, mild valvular regurgitations
(Echo 2025-03-26)
lipid and glucose profiles
- LDL-C 66 mg/dL, HDL-C 22 mg/dL, TG 238 mg/dL, total cholesterol 113
mg/dL (Labs 2025-03-28)
- HbA1c 7.3% and serum glucose 227 mg/dL (Labs 2025-03-26 to
2025-03-28)
renal and hepatic function
- creatinine 1.09 mg/dL, eGFR 72.39 mL/min/1.73m² (Labs
2025-03-26)
- ALT 35 U/L (Labs 2025-03-26)
coagulation status
- PT 10.8 sec, INR 1.02, APTT 40.3 sec (Labs 2025-03-27)
current medications post-NSTEMI and PCI
- dual antiplatelet: Brilinta (ticagrelor), Bokey (aspirin)
- statin: Crestor (rosuvastatin)
- antihypertensives: Diovan FC (valsartan), Norvasc (amlodipine),
Carvedilol Hexal (carvedilol), Apolin (hydralazine PRN)
- antihyperglycemics: Forxiga (dapagliflozin), Uformin (metformin),
Xigduo XR (dapagliflozin/metformin)
- GI protection: Nexium (esomeprazole)
[Assessment]
post-NSTEMI management with PCI and adequate secondary prevention
initiated
- evidence of myocardial injury supported by serial hs-Troponin I and
CKMB elevation (Labs 2025-03-26 to 2025-03-28)
- PCI to LM-LAD was successful without complications (POMR
2025-03-27)
- LVEF preserved (58%) with no RWMA, mild valvular lesions (Echo
2025-03-26)
lipid and glycemic control suboptimal
- despite LDL-C <70 mg/dL, HDL-C is markedly reduced and TG elevated
(Labs 2025-03-28)
- HbA1c 7.3% indicates suboptimal glycemic control (Labs
2025-03-28)
- statin and SGLT2 inhibitor combination may benefit both CV risk and DM
control
COPD with obstructive pattern confirmed
- mild obstructive ventilatory impairment with bronchodilator response
(LFT 2025-03-06)
- current medication list does not include any inhaler for COPD
management
potential drug-related risks
- Brilinta (ticagrelor) + Bokey (aspirin): bleeding risk, monitor for
signs of GI bleeding or bruising
- hypotension risk due to multiple antihypertensives (Diovan FC,
Norvasc, carvedilol, hydralazine PRN)
- bradycardia risk from carvedilol (hold if HR < 60)
[Plan / Recommendation]
optimize cardiovascular protection and medication monitoring
- maintain dual antiplatelet therapy for at least 12 months post-PCI if
no contraindications
- assess bleeding risk regularly
- continue Crestor (rosuvastatin 10mg), consider uptitration if TG
remains elevated
- monitor HR and BP for carvedilol titration; consider reducing dose if
HR < 60 bpm
refine metabolic management
- continue Xigduo XR (dapagliflozin/metformin) for glycemic and CV
benefit
- monitor renal function periodically
- review dietary adherence and physical activity to support HbA1c and TG
reduction
- reinforce lifestyle modification as emphasized in SOAP 2025-03-31
address COPD care
- encourage smoking cessation
patient education and follow-up
- reinforce understanding of dual antiplatelet therapy and the
importance of adherence
- educate patient to monitor for and report bleeding signs, especially
due to dual therapy (reminded again during 2025-04-16 visit)
[MedRec]
[chemotherapy]
[exam finding]
[MedRec]
[Subjective]
Heart failure and fluid overload
- Dyspnea improved following diuretic and rate control therapy
- No current exertional dyspnea reported post-discharge (POMR
2025-04-11)
- Patient adheres well to medications and inquired about the impact of
shift work on heart health (clinic note 2025-04-16)
- Advised to maintain consistent sleep-wake cycles despite night
shifts
- No orthopnea, PND, chest pain, or fever reported
Atrial fibrillation and stroke prevention
- Paroxysmal Af with prior rapid ventricular response (ECG
2025-04-05)
- Converted to sinus rhythm on 2025-04-09; stable rhythm maintained
thereafter
- Patient currently on short-term anticoagulation with apixaban
- No bleeding or adverse effects reported
Medication and self-care adherence
- Strong adherence reported (2025-04-16)
- Patient expressed concern about renal function
- Explained to be moderate CKD; advised to maintain hydration and avoid
NSAIDs
- Patient also inquired about possible benefit from SGLT2 inhibitor; was
advised to discuss with cardiologist at follow-up
[Objective]
Renal function and electrolytes
- Creatinine improved to 0.99 mg/dL on 2025-04-09 from 1.54 mg/dL
(2025-04-05); eGFR 61.45 mL/min/1.73m²
- BUN still elevated at 30 mg/dL (2025-04-09), suggesting ongoing renal
involvement
- Normonatremia and potassium borderline low (K 3.6 mmol/L)
Heart function and imaging
- NT-proBNP significantly elevated: 9405.2 pg/mL (2025-04-05)
- 2D Echo (2025-04-08): Preserved LVEF (56.6%), concentric LVH, mild MR,
moderate TR, IVC and atrial dilatation
Hematology
- Microcytic anemia with HGB 9.5–10.9 g/dL, MCV ~67 fL, RDW 17.2%
- Iron deficiency parameters: Fe 19 ug/dL, TIBC 275 ug/dL, ferritin 70.2
ng/mL
- Known history of thalassemia (clinic note 2025-04-16)
Other labs
- HbA1c 6.1% (2025-04-09): acceptable glycemic control
- Lipid profile (2025-04-09): TC 98, LDL 41, HDL 46 mg/dL – well
controlled
Discharge medications (as of 2025-04-11)
- Cordarone (amiodarone) 200 mg QD
- Eliquis (apixaban) 5 mg BID
- Exforge FC (amlodipine + valsartan) 1 tab QD
- Nakasser SR (diltiazem) 120 mg QD
- Spiron (spironolactone) 25 mg BID
- Uretropic (furosemide) 40 mg QD
[Assessment]
Heart failure with preserved EF (HFpEF)
- Well-controlled clinically post-discharge
- Continued risk of volume overload and elevated filling pressures
(NT-proBNP 9405.2 pg/mL on 2025-04-05)
- Shift work may be a contributing factor; patient counseled on
maintaining stable circadian rhythm
Paroxysmal atrial fibrillation
- Successfully converted to sinus rhythm on 2025-04-09
- Appropriate short-term anticoagulation with apixaban (CHA₂DS₂-VASc =
4)
- Amiodarone planned for short-term rhythm stabilization
Chronic kidney disease (stage 3b)
- Improved creatinine on 2025-04-09 (0.99 mg/dL), eGFR 61.45
mL/min/1.73m²
- Ongoing renal vulnerability with elevated BUN and prior lower eGFR
(36.90 mL/min/1.73m² on 2025-04-05)
- Patient advised to maintain hydration and avoid chronic NSAID use
Thalassemia trait with coexisting iron deficiency anemia
- Microcytic anemia likely multifactorial: iron deficiency (Fe 19 µg/dL)
and thalassemia (clinic note 2025-04-16)
- Ferritin borderline; inflammation or chronic disease may co-exist
Diabetes mellitus
- Stable glycemic control under outpatient management (HbA1c 6.1%)
[Plan / Recommendation]
Heart failure and volume status
- Continue diuretics (Uretropic, Spiron) and ARB-based antihypertensive
(Exforge FC)
- Reinforce daily weight monitoring and fluid intake targets
- Encourage stable sleep schedule despite night shifts to support
autonomic balance
Atrial fibrillation
- Maintain apixaban for stroke prevention, reassess duration at
follow-up
- Continue amiodarone short-term only; monitor thyroid/liver function if
prolonged
- Consider long-term rhythm strategy based on recurrence and
symptoms
Renal support
- Maintain good hydration
- Avoid NSAIDs unless strictly indicated
- Monitor renal function (eGFR, creatinine, electrolytes)
periodically
- Strongly consider adding an SGLT2 inhibitor (e.g., dapagliflozin or
empagliflozin) to benefit both HF and CKD if not contraindicated; to be
discussed with cardiologist
Anemia and thalassemia
- Recommend trial of oral iron supplementation
- If anemia persists, consider hemoglobin electrophoresis follow-up for
more precise thalassemia genotyping
- Avoid excessive iron loading due to thalassemia component
Metabolic and cardiovascular risk control
- Continue statins and antihypertensive therapy
- Periodic lipid panel and HbA1c checks
- Encourage physical activity and dietary salt restriction
[MedRec]
2025-03-20 ~ 2025-04-15 POMR Hemato-Oncology Liu YiSheng
2025-02-11 ~ 2025-02-15 POMR Gastroenterology Chen ZhiXiang
2025-01-24 ~ 2025-01-27 POMR Gastroenterology Chen ZhiXiang
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
2025-03-20 Dermatology
2025-03-19 Rehabilitation
2025-03-16 Cardiology
[Subjective]
cardiovascular events and post-PCI care
- 60-year-old male with dermatomyositis under control, presented with
chest pain and dyspnea since 2025-03-08
- visited YunLin Christian Hospital on 2025-03-13 with suspected NSTEMI;
started on dual antiplatelet therapy
- transferred to this facility with worsening dyspnea on 2025-03-16;
diagnosed with NSTEMI, cardiogenic shock, and pulmonary edema
- PCI on 2025-03-17 with stent placement in LAD, balloon angioplasty for
D1 and LCX with thrombus aspiration
- post-procedure hypotension managed with norepinephrine and
atropine
- dizziness and hypotension persisted; improved with midodrine and
corticosteroid
- pharmacist visited patient on 2025-04-16; patient reported no problems
with medication use and said the herpes simplex on buttock had mostly
healed
gastrointestinal protection and herpes simplex
- Nexium (esomeprazole) started for ulcer prophylaxis
- Buttock vesicular rash (2025-03-20), treated as herpes simplex with
topical acyclovir
[Objective]
vital signs and symptoms
- hypotension (BP 109/60 mmHg on 2025-03-16), cold sweating,
dyspnea
- post-PCI hypotension requiring vasopressor and midodrine support
labs and imaging
- elevated hs-Troponin I 3300.9 pg/mL (2025-03-16), NT-proBNP 4585.7
pg/mL
- echocardiography (2025-03-18): mildly impaired LV systolic function,
EF 46.6% (2D), regional wall motion abnormality
- ECG (2025-03-18): anteroseptal infarct, prolonged QT
- CBC (2025-03-21): HGB 11.1 g/dL, PLT 381 ×10^3/uL, WBC 6.10
×10^3/uL
- cortisol 8.33 ug/dL (2025-03-21), relatively low
- cholesterol: low HDL-C (22 mg/dL), normal LDL-C (100 mg/dL) on
2025-03-17
- iron studies (2025-03-21): Fe 74 ug/dL, TIBC 275 ug/dL, UIBC 201
ug/dL
current medications (2025-03-27 SOAP note)
- Bokey (aspirin 100 mg QD)
- Brilinta (ticagrelor 90 mg BID)
- Crestor (rosuvastatin 10 mg QD)
- Midorine (midodrine 2.5 mg PRN QD if SBP <100)
- Mexium (esomeprazole 40 mg QDAC)
- cortisone acetate 25 mg BID
[Assessment]
post-NSTEMI dual antiplatelet therapy
- appropriate DAPT with aspirin and ticagrelor post-stenting
- gastric protection with esomeprazole reduces risk of GI bleeding
lipid management
- Crestor (rosuvastatin) indicated for secondary prevention
post-ACS
- however, HDL-C remains low (22 mg/dL), additional cardiovascular risk
remains
orthostatic hypotension
- resolved with midodrine and corticosteroid; may reflect adrenal
insufficiency or autonomic dysregulation
- cortisol level borderline low (8.33 ug/dL), justifying corticosteroid
replacement
cardiogenic shock and post-PCI recovery
- improved with vasopressor support and resolution of pulmonary
edema
- current LVEF mildly reduced, but stable
herpes simplex management
- topical acyclovir appropriate for localized HSV infection
- now mostly healed according to patient report on 2025-04-16
medication adherence
- no adverse drug reactions or usage problems reported by patient during
pharmacist visit on 2025-04-16
[Plan / Recommendation]
post-ACS antiplatelet therapy
- continue Bokey (aspirin) 100 mg QD and Brilinta (ticagrelor) 90 mg BID
for at least 12 months unless bleeding occurs
- reinforce adherence and bleeding precautions
lipid management
- continue Crestor (rosuvastatin) 10 mg QD
- consider rechecking lipid profile in 4–8 weeks to assess
response
- if HDL-C remains low and LDL goal not met, consider dose escalation or
add-on therapy (e.g., ezetimibe)
hypotension and adrenal support
- maintain cortisone acetate 25 mg BID as current dose seems to
alleviate hypotension
- consider ACTH stimulation test if long-term corticosteroid use is
expected
- PRN midodrine may be tapered off as BP stabilizes
gastrointestinal protection
- continue Mexium (esomeprazole) 40 mg QDAC with DAPT
- monitor for long-term PPI-related effects if used >8 weeks
infection management
- continue topical acyclovir if any residual lesion persists
- no further intervention needed unless recurrence
medication safety monitoring
- patient showed good adherence and tolerance to current regimen per
pharmacist evaluation on 2025-04-16
- continue patient education and reinforce medication understanding
[lab data]
2025-04-07 BM chromosome analysis CYTOGENETICS LABORATORY REPORT - Chromosome Analysis: - Tissue Examined: Bone marrow - Staining Method: G-Banding - Colony number: NA - Bands level: 500 - Chromosome Counts: 45-(3)、46-(17)、47-()、Other-() Total-(20) - Karyotype: 46,XY17 - Interpretation: - Analysis of this bone marrow sample shows a male having 46,XY17 karyotype. There was no significant clonal chromosomal abnormality detected. Additionally, out of 20 cells analyzed, two cells with [45,X,-Y] and another cell with [45,XY,-21] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time. - Note: - ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.
2025-03-10 HBsAg Nonreactive
2025-03-10 HBsAg Value 0.32 S/CO
2025-03-10 Anti-HCV Nonreactive
2025-03-10 Anti-HCV Value 0.07 S/CO
2025-03-10 Anti-HBc Reactive
2025-03-10 Anti-HBc Value 6.24 S/CO
2025-03-07 FKLC 395.12 mg/L
2025-03-07 FLLC 17.80 mg/L
2025-03-07 FK/FL ratio 22.20 ratio
2025-03-06 Protein, total 9.1 g/dL
2025-03-06 Albumin 24.3 %
2025-03-06 Alpha-1 4.3 %
2025-03-06 Alpha-2 9.7 %
2025-03-06 Beta 18.5 %
2025-03-06 Gamma 43.2 %
2025-03-06 M-peak Positive
2025-03-06 A/G Ratio 0.30
2025-03-06 IgG/A/M Kappa/Lambda IgA + Kappa chain
2025-03-05 IgE <2.00 IU/mL
2025-03-05 ANA Negative
2025-03-04 IgG (blood) 601 mg/dL
2025-03-04 IgA 4805 mg/dL
2025-03-04 IgM 56.0 mg/dL
2025-03-04 C3 120.9 mg/dL
2025-03-04 C4 73.4 mg/dL
[exam finding]
[chemotherapy]
[lab data]
2025-04-12 ACTH 99.0 pg/mL
2025-04-12 Cortisol 33.17 ug/dL
[exam finding]
[consultation]
[MedRec]
[chemotherapy]
The 66-year-old female patient has a known history of myelodysplastic syndrome with refractory anemia with excess blasts (RAEB), which appears to have evolved into acute myeloid leukemia (AML) around 2025-02-24 as evidenced by a transient blast surge to 38.0% (CBC 2025-02-24). Although this blast count subsequently decreased, it surged again to 26.9% on 2025-04-14, confirming AML transformation (WHO criteria: blasts ≥20%). Her clinical condition is further complicated by progressive pancytopenia, severe hypoalbuminemia, hyponatremia, renal over-clearance (likely due to cachexia), high inflammatory markers (CRP up to 23.7 mg/dL on 2025-04-11), suspected enterocolitis (CT 2025-02-24), pruritic skin lesions due to scabies, and possible relative adrenal hyperfunction (ACTH 99.0 pg/mL and cortisol 33.17 µg/dL on 2025-04-12). She remains functionally ECOG PS 2 and afebrile as of 2025-04-15 morning (VS 2025-04-15 08:58).
Problem 1. AML Transformation from MDS
Problem 2. Pancytopenia with Severe Thrombocytopenia and Anemia
Problem 3. Hyponatremia with Hypoalbuminemia and Cachexia
Problem 4. Possible Relative Hypercortisolism
Problem 5. Infectious Inflammation and Scabies
[lab data]
2024-12-17 HSV 1+2 IgM Negative
2024-12-17 HSV 1+2 IgM Value <0.50 Index
2024-12-16 AMA Negative
2024-12-16 ASMA Negative
2024-12-16 FLT3-D835 (BM) Undetectable
2024-12-14 ANCA IU/ml
2024-12-14 PR3 Negative IU/ml
2024-12-14 PR3 Value <0.6 IU/ml
2024-12-14 MPO Negative
2024-12-14 MPO Value 0.2 IU/ml
2024-12-14 EB VCA IgM Negative Index
2024-12-14 EB VCA IgM Value 0.7 Index
2024-12-13 IgG (blood) 1383 mg/dL
2024-12-13 Anti-HAV IgM Nonreactive
2024-12-13 Anti-HAV IgM Value 0.30 S/CO
2024-12-13 CMV IgM Nonreactive
2024-12-13 CMV IgM Value 0.22 Index
2024-12-05 FLT3/ITD (BM) Undetectable
2024-12-05 NPM1 (qual) (BM) Undetectable
2024-12-05 JAK2 mutation (quan) 0.00 %
2024-12-05 BCR/abl (qual) Undetectable
2024-12-02 MPO stain Positive(2+)
2024-12-02 CAE stain Positive
2024-12-02 ANAE stain Positive
2024-11-29 LAP Stain 84 score
2024-11-29 HBsAg Nonreactive
2024-11-29 HBsAg (Value) 0.32 S/CO
2024-11-29 Anti-HBc Reactive
2024-11-29 Anti-HBc-Value 4.13 S/CO
2024-11-29 Anti-HCV Nonreactive
2024-11-29 Anti-HCV Value 0.19 S/CO
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2025-04-10 - cytarabine 30mg/m2 54mg SC D1-7 (low dose Ara-C with oral Venclexta (venetoclax) 100mg QDCC)
2025-02-27 - daunorubicin 45mg/m2 77mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 172mg NS 500mL 24hr D1-5
2025-01-10 - daunorubicin 45mg/m2 80mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 179mg NS 500mL 24hr D1-7
2024-12-06 - daunorubicin 45mg/m2 62mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 92mg NS 500mL 24hr D1-7 (TBI 2.61 => Daunoblastina 75%, Cytosar 50%)
The patient is a 65-year-old man with AML undergoing multiple cycles of chemotherapy (including standard 7+3 and low-dose cytarabine regimens). Despite transient reductions in blast counts and initial marrow hypocellularity, refractory/residual disease persists. His clinical course is complicated by persistent cytopenias (especially thrombocytopenia), intermittent febrile episodes with elevated inflammatory markers, progressive hepatocellular enzyme elevations, and electrolyte disturbances. The latest marrow biopsy (2025-03-20) suggests residual AML, and CBC trends as of 2025-04-14 continue to show pancytopenia with ANC < 500, Hgb ~8.0, and PLT < 30×10³/uL. He also developed anal abscess (2025-03-18 pathology) and hepatotoxicity possibly related to chemotherapy.
Problem 1. Persistent Cytopenia and Residual AML
Problem 2. Febrile Episodes with Infection Risk
Problem 3. Progressive Hepatotoxicity
Problem 4. Hypokalemia
Problem 5. Renal Function Fluctuation
Neutropenia Evaluation
Evaluation of Current Treatment Modalities
Assessment for Treatment Effects
Recommendations
Patient Summary
Problem 1: Acute Myeloid Leukemia (AML)
Problem 2: Cardiac Abnormalities
Problem 3: Chronic Viral Hepatitis B
Problem 4: Renal Dysfunction and Tumor Lysis Risk
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Summary
Problem 1. Metastatic HPV-associated tonsillar squamous cell carcinoma with radiographic and serologic progression
Problem 2. New-onset cognitive decline and urinary incontinence – rule out brain metastasis and other causes
Problem 3. Symptomatic transfusion-dependent anemia, likely chronic GI blood loss from colorectal metastasis
Problem 4. Atrial fibrillation with prior SVT/RVR; rate control without anticoagulation due to active bleeding
Problem 5. Right pleural effusion with adjacent lung collapse; multifocal pulmonary metastases and possible infection risk
Problem 6. Chronic kidney disease stage 2–3 with cisplatin exposure history; currently stable
Problem 7. Analgesia and symptom management; high-risk sedatives
Problem 8. Electrolyte abnormalities: hypomagnesemia; hyperuricemia; borderline calcium
Problem 9. Hepatitis B carrier under immunotherapy/chemotherapy
Problem 10. Nutrition and functional decline
Problem 11. Thromboembolism prophylaxis in high-bleeding-risk cancer inpatient
Problem 12. Indwelling Port-A catheter care
Active inpatient medication list (formatted)
Disposition and immediate next steps (today 2025-10-16)
Medication/treatment-related problems and recommendations (as of 2025-10-16)
Active medications to keep or adjust now (for clarity)
Key immediate actions today (2025-10-16)
[exam finding]
[MedRec]
[Subjective]
chest pain and cardiovascular symptoms
- recent STEMI episode on 2025-03-18
- presented with right chest pain at 4:00 AM
- ECG showed ST elevation at anterior wall
- hs-TnI elevated to 52.0 pg/mL
- admitted for catheterization and intervention
- received DAPT and PCI with POBA + DCB + BMS
past cardiovascular history
- STEMI in 2018, s/p LAD BMS placement
- history of CAD with single vessel disease
- known HFrEF with reduced EF post-MI
- latest LVEF 37.9% (2025-03-18)
- symptoms improved post-PCI and rehab initiation
chronic comorbidities
- essential hypertension
- hyperlipidemia
- idiopathic gout
- GERD without esophagitis
- former smoker (decades of smoking)
[Objective]
vital signs and labs
- BP 186/114 mmHg on 2025-03-18 (at ER)
- K 3.7 mmol/L, Na 141 mmol/L, Cr 1.20 mg/dL, eGFR 69.59
(2025-03-21)
- LDL 52 mg/dL, HDL 35 mg/dL, TG 107 mg/dL, total cholesterol 97
mg/dL
- HbA1c 5.6% (2025-03-21), glucose (AC) 92 mg/dL
- CKMB peaked at 99.2 ng/mL, CK 871 U/L (2025-03-19)
cardiac diagnostics
- ECG: T wave abnormalities, infarct patterns (anteroseptal, septal,
inferior)
- Echo (2025-03-18): LVEF 37.9%, septal/anterior wall akinesis, grade 1
diastolic dysfunction
- Cardiac catheterization (2025-03-18): 1VD (m-LAD instent total
occlusion), s/p PCI with BMS + DCB
medication list
- DAPT: Bokey (aspirin), Brilinta (ticagrelor)
- HF: Carvedilol Hexal, Blopress (candesartan), Jardiance
(empagliflozin), Spiron
- others: Crestor (rosuvastatin), Euricon (benzbromarone), Nexium
(esomeprazole), Nitrostat PRN
- anticoagulation: enoxaparin x 2 days (post-PCI)
[Assessment]
post-STEMI management
- patient adherent to DAPT (aspirin + ticagrelor), post-MI PCI (POBA +
DCB + BMS)
- stabilized with resolution of chest discomfort and hemodynamic
improvement
- education and rehab initiated early with favorable response
heart failure management (HFrEF, NYHA II)
- on appropriate agents: beta-blocker, ARB, MRA, SGLT2 inhibitor
- EF improved from previous 44.8% (M-mode) to 37.9% (Simpson)
post-infarct
- room for diuretic optimization if volume overload occurs
lipid and CV risk
- on Crestor (rosuvastatin 10mg), achieved LDL 52 mg/dL
- HDL remains low (35 mg/dL), room for lifestyle counseling
- smoking cessation discussed
comorbid condition control
- gout managed with Euricon
- GERD addressed with Nexium
- BP still uncontrolled on admission, but appropriate antihypertensives
restarted
[Plan / Recommendation]
optimize cardiovascular pharmacotherapy
- continue DAPT for minimum 12 months post-PCI
- reassess bleeding risk vs ischemic benefit at 3, 6, and 12
months
- continue HF meds (carvedilol, candesartan, spironolactone,
empagliflozin)
- monitor for hypotension, hyperkalemia, and renal function
- consider titration of ARB or beta-blocker as tolerated
lipid management
- maintain rosuvastatin; LDL goal achieved
- consider targeting non-HDL-C and apoB if available
- emphasize diet and physical activity to raise HDL
gout and uric acid
- continue Euricon; uric acid within normal range
- monitor for renal function and urate fluctuations
antiplatelet and anticoagulant use
- ensure Brilinta adherence, monitor for bleeding
- enoxaparin discontinued appropriately after 2 days
BP and metabolic monitoring
- monitor BP control and reintroduce dose titration if persistent
hypertension
- glucose and HbA1c are at goal; no antidiabetic agents needed beyond
empagliflozin
GI protection
- consider tapering off Nexium after DAPT period if no GI symptoms
patient education and rehab
- reinforce smoking cessation
- encourage cardiac rehab participation
- monitor for symptoms of angina, dyspnea, or volume overload
[exam finding]
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
medication use and adherence - patient currently on post-op medications with known indication - Tramacet used for pain control post-amputation - Xarelto FC (rivaroxaban 15mg) used for thromboembolism prevention post-EKOS/PTA - no report of nonadherence or ADR - no bleeding, dizziness, or nausea reported - patient status stable - BP 138/64 mmHg, HR 79 bpm - no active signs of infection or thrombosis - wound care ongoing, stable post-AK amputation - pain improving - dosage of Tramacet tapered from Q6H to Q12H
CV risk factors and medication control - history of hypertension - currently on Norvasc (amlodipine 5mg QD) and Concor (bisoprolol 5mg 0.5# QD) - no diabetes, no reported hyperlipidemia - no smoking or alcohol use noted
procedural and vascular history - acute limb ischemia (2025-03) s/p EKOS thrombolysis and Urokinase - post left above-knee amputation - currently has residual right PAOD and possible thoracic aortic pathology under evaluation
[Objective]
antithrombotic therapy - Xarelto FC (rivaroxaban 15mg) QDCC - correct dose for peripheral arterial disease with high thrombotic risk - no concurrent aspirin noted in recent prescription - coagulation profile stable previously (PT/INR/APTT within range) - no evidence of active bleeding
CV agents - Concor (bisoprolol 0.5# QD), Norvasc (5mg QD) - BP well controlled at 138/64 mmHg - HR 79 bpm, regular rhythm
pain management - Tramacet 1# Q12H - appropriate tapering for post-op control - no new reports of opioid-related side effects
labs and monitoring - potassium 2.8 mmol/L (2025-03-24): persistent mild hypokalemia - renal function stable: Cr 0.66, eGFR 126.82 (2025-03-24) - Hgb stable ~9.8 g/dL, platelets 215 x10³/uL - CRP decreasing trend (2.0 mg/dL on 2025-03-24 vs 8.4 earlier) - no evidence of liver or renal dysfunction
[Assessment]
anticoagulation - Xarelto 15mg QDCC appropriate for secondary prevention after PTA and acute limb ischemia - aspirin is discontinued intentionally by our cardiologist, tapering from dual antithrombotic therapy to NOAC monotherapy - no current bleeding or clotting concern
pain control - pain improving; Tramacet tapering is appropriate - monitor for sedation or constipation as use continues
CV control - blood pressure and heart rate within target - dual-agent antihypertensive regimen appropriate - no statin use noted despite significant atherosclerotic burden
electrolyte imbalance - persistent mild hypokalemia (K 2.8 mmol/L, 2025-03-24) not yet addressed pharmacologically - may predispose to arrhythmia or muscle weakness
nutritional and anemia support - anemia (Hgb ~9.8) likely chronic and post-op related - no active replacement or iron/ferritin monitoring noted - albumin was low during hospitalization (2.7–2.8 g/dL)
[Plan / Recommendation]
antithrombotic management - clarify whether aspirin was discontinued intentionally or omitted - consider low-dose aspirin addition if not contraindicated, especially given high-risk vasculopathy - continue rivaroxaban 15mg QDCC for at least 30–90 days post-intervention - reassess at vascular/cardiology follow-up
electrolyte correction - recommend potassium supplementation - check K level, KCl 600 mg (8 mEq) BID x 3–5 days if needed, then recheck electrolytes - counsel patient on high-potassium dietary sources
CV risk reduction - initiation of statin therapy (e.g., atorvastatin 20mg QD) should be discussed with doctor. - strong atherosclerotic background (aortic thrombus, iliac occlusion, PAOD)
pain and rehabilitation - continue Tramacet 1# Q12H PRN, assess daily pain scores - encourage transition to non-opioid agents as tolerated (e.g., acetaminophen monotherapy) - ensure rehab consult for post-AK amputation mobility plan
nutritional and anemia management - consider CBC + iron panel + reticulocyte count for anemia assessment - monitor serum albumin and prealbumin if wound healing remains suboptimal - consider oral iron (e.g., ferrous sulfate 325mg QD) if IDA confirmed
follow-up and education - reinforce medication adherence - monitor for bleeding (Xarelto), dizziness, fatigue, constipation - arrange chest CTA as planned by cardiology to reassess thoracic aortic status
[exam finding]
[MedRec]
2024-12-29 ~ 2025-01-24 POMR General and Gastrointestinal Surgery Chen YanZhi
2024-11-29 ~ 2024-12-06 POMR Gastroenterology Hong YuLong
2024-07-08 ~ 2024-07-12 POMR Infectious Disease Peng MingYe
2024-02-13 ~ 2024-02-17 POMR Cardiology Xie JianAn
2023-06-03 ~ 2023-06-07 POMR Integrative Medicine Cheng HengXiang
2023-04-19 ~ 2023-04-21 POMR General and Gastroenterological Surgery Wu ChaoQun
2021-12-12 ~ 2021-12-20 POMR Chest Medicine Lan ZhouJin
[surgical operation]
[immunochemotherapy]
[MedRec]
[surgical operation]
[exam finding] (not completed)
[MedRec]
2025-04-02 ~ 2025-04-07 POMR Hemato-Oncology Xia HeXiong
2025-03-26 SOAP Hemato-Oncology Xia HeXiong
2025-03-20 SOAP Cardiology Zhou XingHui
2025-03-16 ~ 2025-03-18 POMR General and Gastroenterological Surgery Zhang JianHui
2025-03-06 SOAP Hemato-Oncology Xia HeXiong
2025-03-06, 2025-02-13, 2025-01-16 SOAP Nephrology Peng QingXiu
2022-07-25 ~ 2022-07-27 POMR Nephrology Peng QingXiu
[surgical operation]
[chemotherapy]
[lab data]
2025-03-07 HBsAg (NM) Negative
2025-03-07 HBsAg Value (NM) 0.386
2025-03-07 Anti-HBc (NM) Positive
2025-03-07 Anti-HBc Value (NM) 0.008
2025-03-07 Anti-HCV (NM) Negative
2025-03-07 Anti-HCV Value (NM) 0.038
2025-03-07 CEA 5.92 ng/mL
2025-03-07 CA199 20.03 U/mL
[exam finding]
[MedRec]
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
[Subjective]
patient status and progress - post-STEMI recovery - stabilized hemodynamics - extubated and ambulatory
[Objective]
current medications - DAPT: Bokey (aspirin 100 mg QD), Brilinta (ticagrelor 90 mg BID) - statin: Crestor (rosuvastatin 10 mg QD) - ezetimibe: Ezetrol (10 mg QD) - beta-blocker: Carvedilol Hexal 6.25 mg BID (hold if SBP < 100 or HR < 60) - PPI: Nexium (esomeprazole 40 mg QDAC) - SGLT2i + metformin: Xigduo XR (dapagliflozin 10 mg + metformin 1000 mg QD) - HBV: Vemlidy (tenofovir alafenamide 25 mg QD)
labs - lipid profile: LDL 167 mg/dL, HDL 32 mg/dL, TG 234 mg/dL, Cholesterol 238 mg/dL (2025-03-17) - HbA1c: 6.9% (2025-03-17) - LFT: ALT 21 U/L, AST 15 U/L (2025-03-16) - CK: 4218 U/L, CKMB: 201.3 ng/mL (2025-03-17) - renal: Cr 0.88 mg/dL, eGFR 98.66 mL/min/1.73m² (2025-03-16)
vitals and tolerance - HR remained above 60 bpm - weight loss noted (87 kg → 81 kg)
[Assessment]
post-MI medication regimen - guideline-concordant therapy for post-STEMI and multivessel CAD - includes DAPT, statin + ezetimibe, beta-blocker, PPI - effective antiplatelet therapy with no bleeding complications - possible hypotension from carvedilol needs monitoring, but currently managed - high-intensity statin + ezetimibe appropriately initiated due to high LDL - ongoing Vemlidy for chronic HBV appropriate with normalized ALT/AST - glycemic control adequate (HbA1c 6.9%) with SGLT2i + metformin
potential optimization - LDL remains above target (< 55 mg/dL for very high-risk patients) - TG borderline elevated, HDL low - beta-blocker dose low - renal and liver functions stable; no contraindication to current meds
[Plan / Recommendation]
lipid control optimization - reinforce adherence to statin + ezetimibe - consider increasing Crestor to 20 mg if tolerated and LDL remains > 55 mg/dL on follow-up
beta-blocker management - continue carvedilol 6.25 mg BID - maintain “hold if SBP < 100 or HR < 60” instruction - consider slow up-titration if patient tolerates and no orthostatic symptoms recur
antiplatelet therapy - continue Bokey + Brilinta for at least 12 months post-PCI - assess bleeding risk regularly
glucose and HBV management - continue Xigduo XR for glycemic and cardiorenal benefit - continue Vemlidy; monitor HBV DNA and ALT every 3–6 months
monitoring and follow-up - check lipid panel and CK in 6-8 weeks - reinforce patient education on orthostatic precautions and medication adherence - reassess renal and liver function periodically
This is a 47-year-old male with multiple comorbidities, including chronic hepatitis B virus (HBV) infection, metabolic dysfunction-associated steatotic liver disease (MASLD), type 2 diabetes mellitus, and dyslipidemia. He experienced a ST-segment elevation myocardial infarction (STEMI) on 2025-03-16 complicated by ventricular fibrillation (VF), in-hospital cardiac arrest (IHCA), and hypoxic respiratory failure, requiring cardiopulmonary resuscitation (CPR), defibrillation, intubation, and urgent percutaneous coronary intervention (PCI) for triple-vessel coronary artery disease (CAD). Post-PCI, he achieved hemodynamic stability and underwent step-down care and rehabilitation. He is on guideline-directed medical therapy (GDMT), including dual antiplatelet therapy (DAPT), statins, beta-blockers, and glucose/lipid-lowering agents.
Problem 1. Acute STEMI with Cardiogenic Shock and Post-Resuscitation Syndrome
Problem 2. Coronary Artery Disease, Triple Vessel Disease
Problem 3. Type 2 Diabetes Mellitus with Cardiovascular Complications
Problem 4. Chronic Hepatitis B with Flare and MASLD
Problem 5. Dyslipidemia
Problem 6. Post-Cardiac Arrest Neurologic and Functional Status
[exam finding]
[MedRec]
[Subjective]
Heart failure and fluid overload - dyspnea improved after NIPPV and IV diuretic therapy - patient reported no chest discomfort or breathing difficulty post-treatment (POMR 2025-03-28) - self-monitoring plan initiated - instructed to monitor urine output and body weight at home (POMR 2025-03-31)
Anticoagulation for atrial fibrillation - no bleeding reported - warfarin education provided - patient and family instructed on importance of compliance and monitoring INR
Chronic kidney disease and anemia - no complaint of dizziness or fatigue - anemia stable around Hgb 9.2–9.6 g/dL (Labs 2025-03-14 to 2025-03-28)
Psychosomatic and cognitive issues - known alcohol-induced amnestic disorder - currently maintained on Vit B1, memantine, and olanzapine (SOAP 2025-03-14) - no acute behavioral change reported
[Objective]
Heart failure and fluid overload - NT-proBNP markedly elevated at 17711.9 pg/mL (2025-03-19) - echocardiography showed LVEF 69.5%, MR/TR/AR/PR, LA/RA dilation (Echo 2025-03-19) - pulmonary edema improved on CXR (2025-03-28) - IV Lasix tapered to oral Uretropic (furosemide) 40mg PRN (POMR 2025-03-31)
Anticoagulation for atrial fibrillation - INR subtherapeutic: 1.04 (2025-03-28), 1.15 (2025-03-31) - warfarin titration from 2 mg → 2.5 mg → 3.5 mg (POMR 2025-03-31) - no signs of active bleeding
Chronic kidney disease and anemia - creatinine rising from 3.87 (2025-03-19) to 4.74 mg/dL (2025-03-28), eGFR 9.59 mL/min/1.73m² - metabolic acidosis (HCO₃⁻ 12.3–16.2 mmol/L) - anemia with Hgb 9.3 g/dL (2025-03-28) - on Mircera (epoetin beta) Q1M SC (SOAP 2025-01-24)
Thyroid function - TSH elevated at 6.182 µIU/mL, Free T4 0.73 ng/dL (2025-03-28) - not on any thyroid replacement
Infection / UTI - UTI confirmed by urinalysis (bacteria 3+, WBCs 30–49/HPF) (2025-03-19) - treated with Zinacef (cefuroxime) empirically
[Assessment]
Heart failure and fluid overload - acute decompensated HFpEF with adequate response to NIPPV, diuretics - ongoing PRN diuretic use appropriate - volume and electrolyte status need close monitoring - no signs of recurrent edema noted
Anticoagulation for atrial fibrillation - warfarin underdosed based on low INR - titration in progress with current dose 3.5 mg daily - CKD stage 5 complicates warfarin metabolism - higher INR fluctuation risk
Chronic kidney disease and anemia - renal function worsened; eGFR <10, approaching dialysis threshold - anemia likely multifactorial (CKD, inflammation), managed conservatively - iron stores suggest functional deficiency (Fe 18 µg/dL, ferritin 277 ng/mL)
Thyroid dysfunction - biochemical hypothyroidism - not currently treated - possible impact from amiodarone
Infection / UTI - recurrent UTI likely from diabetes and residual urinary glucose/protein - no systemic signs at discharge
[Plan / Recommendation]
Heart failure and fluid overload - continue Uretropic (furosemide) 40mg PRN if BW gain >2kg or edema develops - encourage daily weight monitoring - recommend re-evaluation echocardiogram in 3–6 months to monitor valvular burden
Anticoagulation for atrial fibrillation - continue Cofarin (warfarin) 3.5 mg daily - check INR every 3–5 days until stable - avoid drug interactions (e.g., NSAIDs, some antibiotics) - evaluate for pharmacist-driven anticoagulation service if INR control remains suboptimal
Chronic kidney disease and anemia - maintain current Mircera regimen - suggest adding IV iron if TSAT <20% (not yet measured) - recheck iron panel and reticulocyte count - monitor metabolic panel every 2 weeks
Thyroid dysfunction - repeat TSH and Free T4 in 4 weeks - may discuss to consider starting low-dose levothyroxine if TSH remains elevated or symptoms emerge - monitor for bradycardia or angina due to concurrent HF
Infection / UTI - monitor for recurrent symptoms - suggest urine culture and sensitivity for targeted therapy if recurrence - reinforce hygiene, hydration, and glucose control
Other - continue psychosomatic medications (e.g., Zyprexa Zydis (olanzapine), Witgen (memantine), Vit B1) as per Psychiatry - follow up CKD care, consider vascular access planning if symptoms or lab thresholds met
This is a 73-year-old woman with multiple chronic conditions, including heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD) stage 5, paroxysmal atrial fibrillation (AF), and long-standing hypertension and diabetes, complicated by alcohol-induced cognitive disorder. She was recently hospitalized (2025-03-19 to 2025-03-31) for acute pulmonary edema, managed with non-invasive ventilation, intravenous diuretics, and antiarrhythmics. Echocardiogram showed preserved LVEF (69.5%), dilated atria, valvular abnormalities, and atrial fibrillation (AF) (Echo 2025-03-19). Labs show progressively worsening renal function, persistent anemia, elevated TSH with low Free-T4 (suggestive of hypothyroidism), and multiple urinary tract infections (UTIs). There are emerging concerns for electrolyte imbalance, warfarin titration challenges, and malnutrition or underlying chronic inflammation.
Problem 1. Acute Decompensated Heart Failure with Preserved Ejection Fraction (HFpEF)
Problem 2. Paroxysmal Atrial Fibrillation with Subtherapeutic Anticoagulation
Problem 3. Chronic Kidney Disease (CKD) Stage 5
Problem 4. Anemia of Chronic Disease and CKD
Problem 5. Recurrent Urinary Tract Infections
Problem 6. Subclinical Hypothyroidism
[INR Range]
For this simulated patient with paroxysmal atrial fibrillation, heart failure with preserved ejection fraction (HFpEF), hypertension, type 2 diabetes mellitus, and age ≥75, the recommended target INR range is 2.0 to 3.0.
Rationale
Conclusion:
[exam finding]
[MedRec]
[consultation]
[Subjective]
Cardiovascular symptoms - chest discomfort improved after PCI - no current chest pain or pressure - no cold sweating or palpitations reported - orthopnea improved - patient previously reported dyspnea at rest - no current dyspnea on exertion - dizziness on 2025-03-16 - related to hypotension - resolved with midodrine and IV saline
Heart failure history - history of HFrEF, NYHA class IV upon admission - improved to NYHA class II by discharge - no recent orthopnea or edema reported
Diabetes control - no reported hypoglycemia or polyuria - appetite stable post-PCI
Adherence and side effects - no reported intolerance to medications - patient and family declined CABG and opted for PCI - understands need for long-term DAPT
[Objective]
Cardiovascular status - 2025-03-11 cardiac catheterization - LM 50%, LAD 79%, LCX 94%, RCA 75% - PCI with DES x3 to RCA, LAD, LCX - 2025-03-07 echocardiography - LVEF 39.7% (Simpson), global hypokinesia - moderate MR, dilated LA - 2025-03-17–03-13 CXR - resolved pulmonary edema - persistent bilateral pleural effusion - 2025-03-12 ECG: LVH, possible inferior infarct - NT-proBNP 10761.4 pg/mL on 2025-03-10
Renal function - creatinine ranged 1.40–1.60 mg/dL - eGFR 45–53 mL/min/1.73m²
Electrolytes and anemia - K 3.3–3.6 mmol/L - Hgb 10.5–11.0 g/dL, ferritin 164 ng/mL, Fe 28 µg/dL - TIBC 281, transferrin 233.8 mg/dL
Medications as of 2025-03-27 - Efient (prasugrel 3.75mg QD) - Bokey (aspirin 100mg QD) - Carvedilol 6.25mg 0.5# QD - Spironolactone 25mg QD - Forxiga (dapagliflozin 10mg QDAC) - Furosemide 40mg PRN - Nexium (esomeprazole 40mg QDAC) - Foliromin (ferrous sodium citrate 50mg QD) - Crestor (rosuvastatin 10mg QD)
[Assessment]
Coronary artery disease post-PCI - underwent successful PCI with DES to RCA, LAD, LCX - appropriate use of DAPT (prasugrel + aspirin) - no active ischemic symptoms post-discharge - patient at high ischemic risk due to LM and 3VD - surgical revascularization was declined - optimal medical therapy is essential
Heart failure with reduced EF (HFrEF) - appropriate guideline-directed medications: beta-blocker, MRA, SGLT2i - ACEI/ARB/ARNI not included in regimen - unclear if omitted due to prior hypotension or renal risk - NYHA class improved from IV to II - good response to IV diuretics and isoket
Chronic kidney disease - CKD stage 3b likely due to hypertensive/ischemic origin - renal function stable post-diuresis - cautious diuretic use and nephroprotective therapy appropriate
Anemia, likely chronic disease/iron-restricted - borderline microcytic anemia, iron profile suggestive of functional iron deficiency - appropriate oral iron started - no overt bleeding signs, but on DAPT
Diabetes mellitus - HbA1c 5.7% may reflect chronic control or transient drop due to illness - Forxiga offers both glycemic and cardiorenal benefits
Dyslipidemia - LDL 133 mg/dL not at target for secondary prevention (<70 mg/dL) - rosuvastatin 10mg is moderate-intensity
[Plan / Recommendation]
Coronary artery disease post-PCI - continue DAPT (prasugrel + aspirin) for ≥12 months - reassess bleeding risk at 3-month intervals - add PPI (Nexium) appropriate for gastroprotection
Heart failure with reduced EF (HFrEF) - initiate low-dose ACEI (e.g., ramipril 1.25mg QD) if BP and K+ allow - reassess after 1 week - continue carvedilol, spironolactone, Forxiga - educate patient on daily weight, salt/fluid restriction, signs of volume overload
Chronic kidney disease - continue Forxiga for cardiorenal benefit - avoid NSAIDs and nephrotoxic agents - reassess renal panel monthly - consider ACR for proteinuria monitoring
Anemia - continue oral iron (Foliromin) - check reticulocyte count, stool OB - monitor CBC every 2–4 weeks
Diabetes mellitus - continue Forxiga monotherapy - recheck HbA1c in 3 months - monitor for hypoglycemia, especially during poor appetite or infection
Dyslipidemia - consider uptitrating rosuvastatin to 20mg QD or adding ezetimibe - recheck lipid panel in 6–8 weeks
Rehabilitation and follow-up - encourage continued participation in cardiac rehab - ensure medication adherence and BP/HR self-monitoring - follow-up in cardiology within 1–2 weeks
The patient (69-year-old male with NSTEMI, HFrEF, CAD with LM+3VD, T2DM, HTN, and hyperlipidemia)
Problem 1. Coronary Artery Disease (LM + 3VD) post-NSTEMI and PCI
Problem 2. Heart Failure with Reduced EF (HFrEF), ischemic origin
Problem 3. Chronic Kidney Disease (likely Stage 3b)
Problem 4. Type 2 Diabetes Mellitus
Problem 5. Anemia
Problem 6. Hyperlipidemia
Problem 7. Post-MI Cardiopulmonary Rehabilitation
Potential Gaps / Additional Considerations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
The patient is a 78-year-old female diagnosed with synchronous moderately differentiated adenocarcinomas of the cecum and hepatic flexure with liver metastasis (pT3(m)N0, if cM1, AJCC stage IVA) confirmed on 2024-11-28 pathology. Additional KRAS G12A mutation (RAS mutation report 2024-12-04) and persistent liver lesions including a suspected intraductal cholangiocarcinoma or IPNB (MRI 2024-12-25; EUS 2025-01-09) complicate disease management.
The patient underwent laparoscopic right hemicolectomy on 2024-11-28, followed by systemic chemotherapy with Avastin + FOLFIRI, adjusted to 75% dose due to age and frailty (sessions on 2025-02-07, 2025-03-07, 2025-03-31). Tumor markers including CEA and CA199 have rebounded post-chemotherapy, raising concern for progressive disease. Anemia persists, likely multifactorial (chronic disease, malignancy, prior iron deficiency).
Overall, the disease appears progressive despite systemic therapy. Liver lesions show necrosis and atypical cells on biopsy, but viable tumor remains in other locations, suggesting mixed treatment response.
Problem 1. Progressive Metastatic Colorectal Cancer with Liver Involvement
Problem 2. Chronic Normocytic Anemia (Likely Multifactorial)
Problem 3. Hepatic and Biliary System Involvement (IPNB/Cholangiocarcinoma?)
Problem 4. Renal Function Preservation Despite Chemotherapy (not posted)
[lab data]
[exam finding]
[MedRec]
[S – Subjective]
Patient: 50-year-old female Chief Complaint: Seeking evaluation for weight management medication.
History of Present Illness (HPI):
Past Medical History (PMH):
Medications:
Lifestyle & Social History:
[O – Objective]
Anthropometrics:
Laboratory Data (2024-11-07):
[A – Assessment]
Obesity (BMI 25–30 kg/m²)
Hyperlipidemia (Persistent, untreated)
Previously noted elevated blood glucose, but last data point normal (Glucose 90 mg/dL, HbA1c 5.4%)
Pharmacologic Weight Management: Evaluation of Available Options. The patient is a candidate for GLP-1 receptor agonists (GLP-1 RAs) based on BMI and history of metabolic risk factors. Available options at this hospital include:
| Medication | Administration | Weight Loss Effect | Key Benefits | Common Side Effects | Notes |
|---|---|---|---|---|---|
| Semaglutide (Wegovy, Ozempic, Rybelsus) | Weekly (inj) or Daily (oral) | High | Once-weekly dosing, strong weight loss effect | GI upset, nausea, vomiting, delayed gastric emptying | Ozempic is for diabetes, Wegovy is for weight loss |
| Liraglutide (Saxenda, Victoza) | Daily (inj) | Moderate | FDA-approved for weight loss (Saxenda) | GI upset, nausea, increased heart rate | Requires daily injection |
| Dulaglutide (Trulicity) | Weekly (inj) | Low to moderate | Cardiovascular benefit, once-weekly dosing | GI upset, possible thyroid risk | Not FDA-approved for weight loss |
[P – Plan / Recommendations]
Pharmacologic Weight Management: Recommended Choice:
Monitoring and Follow-Up for Weight Loss Therapy:
Hyperlipidemia Management Suggestion:
Patient Education (Adverse Effects & Precautions):
Follow-Up Suggestion:
Final Summary:
[exam finding]
[MedRec]
This is a 77-year-old male with a complex medical history, including type 2 diabetes mellitus, chronic kidney disease (CKD stage 3a), mixed hyperlipidemia, and atherosclerotic cardiovascular disease (ASCVD) post-stent ×2 (2024-12). He also has a recent diagnosis of immune thrombocytopenia (ITP) treated with Danol (danazol) and Compesolon (prednisolone), followed by a brief pulse of Medason (methylprednisolone).
He recently underwent neuroimaging revealing a chronic subdural hematoma (SDH) with mild mass effect (CT 2025-03-28), most likely secondary to severe thrombocytopenia. Blood sugar fluctuations are evident, likely aggravated by corticosteroid use. Current vital signs are stable (2025-03-31), with no signs of active bleeding, infection, or decompensation.
Problem 1. Immune Thrombocytopenia (ITP)
Problem 2. Chronic Subdural Hematoma (SDH)
Problem 3. Type 2 Diabetes Mellitus with Steroid-Induced Hyperglycemia
Problem 4. Chronic Kidney Disease (Stage 3a)
Problem 5. Atherosclerotic Cardiovascular Disease (ASCVD)
[Analysis on the appropriateness and risk-benefit considerations of antiplatelet or antithrombotic treatment]
This 77-year-old male patient has
[exam finding]
[MedRec]
[consultation]
[MultiTeam]
[radiotherapy]
[chemotherapy]
Problem 1. Metastatic Sigmoid Colon Adenocarcinoma with Disease Progression
Problem 2. Cancer-Related Pain and Symptom Management
Problem 3. Small Bowel Obstruction (SBO)
Problem 4. Myelosuppression and Prior Neutropenia
Problem 5. Nutritional and Functional Decline
[Summary]
The patient is a 50-year-old male with a history of sigmoid colon adenocarcinoma (diagnosed in 2023-05) and metastases to the liver and lungs. His clinical course has been complicated by disease progression despite multiple chemotherapy regimens, including Panitumumab + FOLFOXIRI, Avastin + FOLFOXIRI, and palliative treatments such as radiotherapy. The patient also suffers from breakthrough cancer pain, managed with a multimodal analgesic regimen, and has signed an advance directive for palliative care.
Recent data (2025-01-15) indicate the patient is receiving FOLFOXIRI with dose reductions and shows mild anemia, stable renal function, and well-compensated liver function. There are indications of cancer progression (e.g., metastases to liver and lungs). He reports psychosocial distress related to family dynamics and unresolved financial and personal concerns.
[Problems]
Problem #1: Cancer Progression (Colorectal Cancer with Metastases)
Problem #2: Cancer Pain (Breakthrough and Chronic)
Problem #3: Mild Anemia (not posted)
Problem #4: Electrolyte Imbalance (not posted)
Problem #5: Psychosocial Distress (not posted)
Problem #6: Neutropenia (resolved)
[palliative care approach for metastatic colon cancer]
The patient’s medical seeking behavior reflects a pattern of frequent visits to emergency care due to severe symptoms related to advanced sigmoid colon cancer with liver and lung metastases. The patient presents with symptoms such as abdominal pain, vomiting, breakthrough cancer pain, and infection-related concerns, often prompting visits to emergency departments.
The patient appears to seek medical attention primarily when experiencing acute or intolerable symptoms, such as severe abdominal pain (often rated as 8-10 on the VAS scale), breakthrough pain, or gastrointestinal complications (vomiting, cramping). These symptoms often align with cancer progression or complications from treatments.
In multiple instances, the patient self-reports worsening pain or new symptoms, such as fever, chills, or abdominal rigidity, indicating a tendency to seek help when experiencing significant discomfort rather than routine monitoring. Additionally, there are frequent prescriptions of pain medications (tramadol, acetaminophen, and morphine), indicating a need for continuous pain management.
The patient, a 50-year-old male with stage IV sigmoid colon cancer and metastases to the lungs and liver, has been experiencing ongoing symptoms and complications requiring frequent hospital visits for treatment and symptom management. His condition has progressed over recent months, with recurrent abdominal pain, vomiting, and severe breakthrough pain prompting multiple admissions to emergency care.
Recent Diagnoses:
Recent Imaging
Recent Treatment & Medications:
Management Plan may include:
Oral Const-K is being used for potassium supplementation, Sintrix (ceftriaxone) for suspected infection, Lactul (lactulose), Through (sennoside), and Bisadyl (bisacodyl) for constipation, and morphine and Tramacet for pain control. No medication issues have been identified.
[lab data]
2024-10-22 HLA A-high 11:02
2024-10-22 HLA A-high 33:03
2024-10-22 HLA B-high 46:01
2024-10-22 HLA B-high 58:01
2024-10-22 HLA C-high 01:02
2024-10-22 HLA C-high 03:02
2024-10-22 HLA DQ-high 02:01
2024-10-22 HLA DQ-high 03:03
2024-10-22 HLA DR-high 03:01
2024-10-22 HLA DR-high 09:01
2024-10-04 Anti-HBc Nonreactive
2024-10-04 Anti-HBc Value 0.17 S/CO
2024-10-04 Anti-HBs 97.56 mIU/mL
2024-10-04 Anti-HCV Nonreactive
2024-10-04 Anti-HCV Value 0.09 S/CO
2024-10-04 HBsAg Nonreactive
2024-10-04 HBsAg Value 0.35 S/CO
[exam finding]
[MedRec]
[chemotherapy]
2025-03-12 - fludarabine 30mg/m2 49mg NS 500mL 30min D1-5 + cytarabine 2000mg/m2 3300mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 13mg NS 50mL 10min D1-3 (FLAG-Ida)
2025-02-10 - fludarabine 30mg/m2 49mg NS 500mL 30min D1-5 + cytarabine 2000mg/m2 3300mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 13mg NS 50mL 10min D1-3 (FLAG-Ida)
2024-12-15 - L-asparaginase 6000unit/m2 9300unit NS 500mL 2hr D1,3
2024-12-09 - L-asparaginase 6000unit/m2 9300unit NS 500mL 2hr D1,3,5 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1
2024-12-04 - daunorubicin 30mg/m2 47mg NS 100mL 30min D1-2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + cyclophosphamide 750mg/m2 1200mg NS 500mL 2hr D1
2024-11-20 - vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + L-asparaginase 6000unit/m2 9696unit NS 500mL 2hr D1,3,5
2024-11-13 - daunorubicin 50mg/m2 80mg NS 100mL 30min D1-3 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + cyclophosphamide 750mg/m2 1200mg NS 500mL 2hr D1
2024-11-08 - methotrexate 15mg IT 2min
2024-11-06 - methotrexate 15mg IT 2min
2024-10-11 - cyclophosphamide 750mg/m2 1200mg NS 500mL 2hr D1 + doxorubicin 50mg/m2 80mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 300mg/m2 490mg NS 25mL 3hr D1-3 + prednisolone 60mg/m2 50mg BID PO D2-5
FLAG-Ida - [Acute myeloid leukemia: Induction therapy in medically fit adults] - 2025-02-10 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
GRAALL-2003 trial - Regimens and Protocols — http://caprockhematology.com/Site/Archive_files/JCO%202009%20GRAAL%20Trial.pdf
The GRAALL-2003 study, conducted in 70 centers across France, Belgium, and Switzerland, investigated a pediatric-inspired treatment approach for adults (aged 15 to 60 years) diagnosed with Philadelphia chromosome-negative acute lymphoblastic leukemia (ALL).
The key aspects of the GRAALL-2003 protocol included:
Detailed Chemotherapy Regimen (Table 1 in the source provides a comprehensive breakdown of the GRAALL-2003 chemotherapy regimen. However, be aware that some errors in the table are corrected in an erratum at the end of the document. Here’s a summary of the key stages, incorporating the erratum’s corrections):
Problem 1. Neutropenia with Febrile Episode
Problem 2. Acute T-Cell Lymphoblastic Leukemia / Lymphoblastic Lymphoma (Refractory Disease Status)
Problem 3. Bone Marrow Suppression (Pancytopenia)
Problem 4. Hepatic Enzyme Elevation (Transaminitis)
The patient, diagnosed with acute lymphoblastic leukemia/lymphoma (ALL/LBL), has experienced significant complications including massive pleural effusion, mediastinal and neck lymphadenopathy, bone marrow involvement, and neutropenia secondary to aggressive chemotherapy. Management strategies have included multiple lines of chemotherapy (e.g., FLAG-Ida), antibiotics for neutropenic prophylaxis, and supportive care for associated symptoms like anemia and pleural effusion. While neutropenia persists as a critical concern, other parameters such as pleural effusion are under control following therapeutic interventions.
Problem 1. Neutropenia
Problem 2. Pleural Effusion
Problem 3. ALL/LBL Progression and Treatment Response
Key Findings and Insights:
Comments on Neutropenia and Thrombocytopenia:
Management Recommendations:
Clinical Improvements:
Patient Overview
Analysis of Current Regimen Alignment with GRAALL-2003 Protocol – For a 27-year-old male, a pediatric-inspired protocol, like GRAALL-2003, is appropriate as it has shown improved survival in young adults with ALL.
Patient-Specific Adjustments – The patient is 27 years old and can tolerate intensified regimens better than older adults, but certain considerations remain critical:
[FFP Not a Universal Fix for L-Asparaginase-Induced DIC]
Fresh frozen plasma (FFP) is not universally beneficial for all patients with disseminated intravascular coagulation (DIC) when receiving L-asparaginase. The use of FFP in such cases has been studied with varying outcomes:
Effectiveness and Risks: FFP is used to manage coagulation disorders induced by L-asparaginase, which can cause deficiencies in several hemostatic proteins, including fibrinogen and antithrombin III5. However, its administration carries risks such as hypervolemia and potential viral transmission5. Studies have shown that FFP does not significantly improve hemostatic parameters or prevent bleeding in some contexts, such as in critically ill neonates with DIC3.
Thrombosis Prevention: While FFP has been used to prevent thrombotic complications associated with L-asparaginase therapy, its effectiveness is debated. In adults undergoing induction therapy with L-asparaginase for acute lymphoblastic leukemia (ALL), the risk of thrombosis is high, but no clear guidelines exist on the use of FFP for thrombosis prevention2. Instead, low molecular weight heparin has been used as a prophylactic measure2.
Clinical Studies: Some studies have shown that FFP does not significantly alter coagulation parameters or improve outcomes in children receiving L-asparaginase7. For instance, a study found no beneficial effect on the hemostatic system in children receiving L-asparaginase when treated with FFP7. Another study demonstrated minimal improvement in coagulation factors after FFP administration during ALL induction therapy8.
In conclusion, while FFP may be used in certain situations to manage coagulation disorders during L-asparaginase therapy, it is not universally effective for all patients with DIC. The decision to use FFP should be based on individual patient conditions and weighed against potential risks.
Citations: 1 https://www.semanticscholar.org/paper/e958fc7411b21acd7aaeaa0939d5a58ed1c3aaf1 2 https://www.semanticscholar.org/paper/855c9f52e9e012acf7ebe9715598f7216ed1e021 3 https://www.semanticscholar.org/paper/a7e99b199d4ede1ae884bfe53c2f336cd9248a9b 4 https://pubmed.ncbi.nlm.nih.gov/3855365/ 5 https://www.semanticscholar.org/paper/d4d1f13b6ecef34499ae64e130de9920e13386ee 6 https://www.semanticscholar.org/paper/b1109ea19930e08070234b800a5b2a3f2309452f 7 https://pubmed.ncbi.nlm.nih.gov/7524313/ 8 https://pubmed.ncbi.nlm.nih.gov/8566890/
[MedRec]
[chemotherapy]
A 49-year-old female with newly diagnosed ascending colon adenocarcinoma (cT3N1b, pT3N1b, stage III, pMMR) underwent right hemicolectomy on 2025-03-10, followed by Port-A implantation on 2025-03-26. She is now admitted for first cycle (C1) of adjuvant FOLFOX chemotherapy on 2025-03-31. Laboratory tests reveal normofunctional liver and kidneys, moderate anemia (HGB 9.0 g/dL), and marked eosinophilia (14.5%). Her chemotherapy plan follows NCCN guidelines, appropriate for stage III colon cancer.
Problem 1. Stage III Colon Adenocarcinoma (pT3N1b, pMMR)
Problem 2. Anemia
Problem 3. Eosinophilia
Problem 4. Chemotherapy Readiness and Organ Function
Problem 5. Hepatitis B Reactivation Risk
[bedside visit]
Date & Time of Visit: 2025-03-31 at 15:30
Location: 11A15
Assessment & Intervention:
During the visit, the patient was awake and alert, lying in bed with good overall spirit. A male family member or friend was also present, seated on the small bed near the window.
I asked the patient how she felt about her first cycle of chemotherapy, and whether she had been informed of the potential side effects. The patient responded that a case manager had provided a brief explanation earlier in the morning, and that she was not currently experiencing any discomfort.
I reminded her to promptly report any adverse symptoms to the healthcare team if they occur. I also informed her that after discharge, she may receive a follow-up call to inquire about her post-chemotherapy condition.
[exam finding] (not completed)
[MedRec]
2020-10-24, 2020-07-11 SOAP Obstetrics and Gynecology Hong ZhengXiu - Prescription x3 - spironolactone 25mg 1# QD 28D - Uformin (metformin 500mg) 0.5# BIDAC 28D
[surgical operation]
[radiotherapy]
[immunochemotherapy]
2025-03-24 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min
2025-02-27 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 148mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-02-05 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-01-15 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-12-25 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-12-04 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2024-11-09 - Phesgo (pertuzumab 1200mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP, loading)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Patient
This 64-year-old female has two concurrent advanced malignancies:
She also has multiple chronic comorbidities: systemic lupus erythematosus (SLE), type 2 diabetes mellitus (currently with hyperglycemia), hypertension, dyslipidemia, hypothyroidism, prior myocardial ischemia, bilateral profound sensorineural hearing loss, and a right pituitary macroadenoma.
She is undergoing intensive treatment with associated risks of myelosuppression, infection, metabolic complications, and cardiovascular concerns.
Problem 1. Advanced High-grade Serous Ovarian Carcinoma (FIGO IIIA1(i))
Problem 2. Triple-negative Invasive Breast Carcinoma (ER-/PR-/HER2 equivocal, ISH-)
Problem 3. Type 2 Diabetes Mellitus with Steroid-induced Hyperglycemia
Problem 4. Cardiovascular Risk: History of Myocardial Ischemia + Ongoing Chemotherapy
Problem 5. Chronic Anemia – Likely Multifactorial (Iron Deficiency, Chronic Disease)
Problem 6. Systemic Lupus Erythematosus (SLE) – Stable
Problem 7. Hypothyroidism – Stable on Replacement
Problem 8. Bilateral Sensorineural Hearing Loss
[Findings and Recommendations]
[Dual Cancer Management: HGSOC and TNBC]
Managing a patient with two distinct primary malignancies - high-grade serous ovarian cancer (HGSOC) and triple-negative breast cancer (TNBC) - is undoubtedly complex. Concurrent or sequential treatment regimens must balance efficacy with minimizing toxicity and adverse reactions.
There is some overlap in regimens that can be used to target both high-grade serous ovarian cancer (HGSOC) and triple-negative breast cancer (TNBC).
Management Options
[exam finding]
[consultation]
This consultation is therefore requested to advise on subsequent treatment and examinations that should be arranged. - A - This 62-year-old woman has been newly diagnosed with nasopharyngeal carcinoma (NPC), confirmed by biopsy at LMD. She was admitted for cancer workup, including MRI, abdominal ultrasound, and PET/CT scan. We have been consulted regarding her case. - Please check the following: - EBV viral load - Anti-HBc - HBsAg - Anti-HCV - We will see the patient and explain the treatment plan in more detail once staging is complete. If the staging reveals T2 or higher, or if lymph node involvement is present (N-positive), please consult general surgery for port-A implantation.
[radiotherapy]
[chemotherapy]
Patient
Problem 1. Nasopharyngeal Carcinoma (Stage cT2N3M0)
Problem 2. Hematologic Suppression (Anemia, Leukopenia, Thrombocytopenia)
Problem 3. Chronic Hyponatremia and Hypokalemia
Problem 4. Nutritional and Mucosal Status (not posted)
Problem 5. Cardiopulmonary Status
[exam finding] (not completed)
[MedRec]
Patient: 51-year-old male, post-STEMI with PCI to LAD
Subjective
Objective
Assessment
Plan / Recommendation
Subjective:
The patient, a 64-year-old male, reports experiencing erectile dysfunction characterized by the ability to achieve an erection but with insufficient duration and hardness, lasting less than five minutes after penetration. He is seeking options for improvement.
He also mentioned a history of hypertension several years ago, which he believes is now resolved through consistent exercise and weight loss. He has not sought recent medical evaluation or taken any long-term medications.
During the consultation, it was revealed that his wife, who is five years younger and postmenopausal, experiences vaginal dryness and pain during intercourse. She perceives that their age makes sexual activity inappropriate, further contributing to their difficulties.
Objective:
Assessment:
Plan / Recommendation
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-03-25 - pembrolizumab 200mg NS 100mL 30min + gemcitabine 1000mg/m2 1800mg NS 100mL 30min
2025-02-27 - liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr + NS 500mL 2hr + cisplatin 70mg/m2 130mg NS 500mL 2hr + KCl 10% 5mL MgSOr 10% 20mL NS 500mL 2hr
2025-01-22 - liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr + carboplatin AUC 5 700mg NS 250mL 2hr
2025-12-30 - liposome doxorubicin 30mg/m2 60mg D5W 250mL 1hr + carboplatin AUC 5 700mg NS 250mL 2hr
2024-11-08 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + docetaxel 75mg/m2 140mg NS 250mL 6hr + carboplatin AUC 4 560mg NS 250mL 2hr
2024-10-07 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + docetaxel 75mg/m2 140mg NS 250mL 6hr + carboplatin AUC 4 600mg NS 250mL 2hr
2024-09-09 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-08-14 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-07-22 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-07-01 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-06-11 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-05-20 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-04-29 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-04-08 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-03-18 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-02-26 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-01-31 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-01-09 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-12-12 - ……………………………………. paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (……… paclitaxel + carboplatin; Q3W)
2023-11-09 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-10-09 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 5 700mg NS 250mL 2hr + [docetaxel 30mg/m2 55mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr
2023-09-18 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr + [docetaxel 30mg/m2 54mg + cisplatin 30mg/m2 54mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr
2023-08-28 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
2023-08-24 - bevacizumab 5mg/kg 600mg NS 500mL 90min (Avastin)
2023-08-07 - [liposome doxorubicin 30mg/m2 60mg D5W 250mL + carboplatin AUC 5 750mg NS 250mL] IP 90min (HIPEC)
2023-07-04 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-06-12 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-05-22 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
This is a 60-year-old woman with high-grade serous carcinoma of the ovary, initially diagnosed at FIGO stage IVB with widespread peritoneal and nodal metastases, and later found to have thyroid metastasis with extensive nodal involvement (Pathology 2024-12-13). She underwent neoadjuvant chemotherapy (Taxol/Carboplatin), debulking surgery with HIPEC (2023-08-07), and later a near-total thyroidectomy with radical neck dissection (2024-12-13). Disease progression was documented radiologically and clinically, with increasing CA125 (1488 on 2025-03-04), worsening anemia (Hgb 6.5–8.0 g/dL, G3, 2025-03-25), new spinal symptoms (CT 2025-03-05: L3-S1 spondylolisthesis and severe central stenosis), and persistent lymphadenopathy. She is currently receiving gemcitabine plus pembrolizumab chemotherapy (C1 on 2025-03-25) and supportive care for severe anemia, fatigue, and back pain.
Problem 1. High-grade serous ovarian carcinoma with metastases (FIGO IVB)
Problem 2. Severe anemia (G3)
Problem 3. Lumbar spondylolisthesis and spinal stenosis with cancer-related back pain
Problem 4. Metastatic thyroid involvement and neck lymphadenopathy
Problem 5. Cardiopulmonary and vascular comorbidity (HTN, prior DVT) (not posted)
[Navigating Treatment Challenges in Recurrent Ovarian Cancer]
Overview of Treatment Timeline and Disease Progression
Evidence of Disease Recurrence and Current Management
Current Chemotherapy Regimen and Consideration for Alternative Options
Recommendations for Next Steps
[sustained response to neoadjuvant and adjuvant therapy]
The patient underwent 3 cycles of paclitaxel and carboplatin neoadjuvant chemotherapy between 2023-05-22 and 2023-07-04. On 2023-08-07, she underwent surgery for ovarian cancer debulking, removal of intraabdominal malignant tumors, omentectomy, adhesiolysis, and HIPEC. Since then, she has received several cycles of paclitaxel and carboplatin adjuvant therapy. Both tumor markers, CA125 and CEA, continue to decrease, suggesting that the treatment is still effective.
2023-10-20 CA-125 (NM) 24.145 U/ml
2023-10-03 CA-125 (NM) 30.618 U/ml
2023-09-11 CA-125 (NM) 53.641 U/ml
2023-08-29 CA-125 (NM) 58.890 U/ml
2023-07-25 CA-125 (NM) 105.698 U/ml
2023-07-07 CA-125 (NM) 945.500 U/ml
2023-06-27 CA-125 (NM) 1417.280 U/ml
2023-06-06 CA-125 (NM) 1071.020 U/ml
2023-05-13 CA-125 782.100 U/mL
2023-10-20 CEA (NM) 6.433 ng/ml
2023-10-03 CEA (NM) 7.930 ng/ml
2023-09-11 CEA (NM) 9.771 ng/ml
2023-08-29 CEA (NM) 8.772 ng/ml
2023-07-25 CEA (NM) 74.188 ng/ml
2023-07-07 CEA (NM) 113.983 ng/ml
2023-06-27 CEA (NM) 95.131 ng/ml
2023-06-06 CEA (NM) 22.970 ng/ml
2023-04-22 CEA 17.240 ng/mL
Based on the PharmaCloud database, our hospital has been the exclusive healthcare provider for this patient in the past three months. Additionally, according to HIS5 records, our cardiologist issued a repeat prescription on 2023-08-18, which included Xarelto (rivaroxaban), Ulstop (famotidine), and Concor (bisoprolol). All of these medications have been added to the active medication list, and there were no issues identified during the reconciliation process.
[exam finding]
[immunochemotherapy]
Patient Evaluation
Problem 1. Metastatic Rectal Adenocarcinoma (T3N1bM1a, Stage IVA)
Problem 2. Liver Function and Transaminitis
Problem 3. Hematologic Abnormalities: Anemia
Problem 4. Electrolyte Imbalance: Hypokalemia
Problem 5. Psychiatric Support and Gastrointestinal Symptom Control
[lab data]
2025-03-18 Cyclosporine-A 101.2 ng/mL
2024-03-18 Cyclosporine-A (NM) 563.0 ng/mL
2024-03-12 Cyclosporine-A (NM) 1129.8 ng/mL
2024-03-06 Cyclosporine-A (NM) 461.0 ng/mL
2024-03-04 Cyclosporine-A (NM) >2000.0 ng/mL
2024-02-23 Cyclosporine-A (NM) >2000.0 ng/mL
2024-01-29 Cyclosporine-A 227.2 ng/mL
2024-01-25 Cyclosporine-A 88.2 ng/mL
[exam findings]
[MedRec]
[chemotherapy]
Note: Triple IST (hATG, CsA, EPAG) - Triple immunosuppressive therapy (IST) for severe AA (SAA) comprises eltrombopag (EPAG; a bone marrow stimulating agent) plus two immunosuppressive agents (horse antithymocyte globulin [hATG] and cyclosporine [CsA]). As discussed above, triple IST is generally preferred over treatment with hATG plus CsA alone (no eltrombopag). Ref: 2024-01-22 https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults
Problem 1. Severe Pancytopenia (Worsening)
Problem 2. Immunosuppressant Monitoring (Improved) (not posted)
Problem 3. Normofunctioning Organ Systems (Stable)
Problem 4. Type 2 Diabetes Mellitus (Discontinued Sitagliptin) (not posted)
Key Summary
Problem 1. Cyclosporine Level Fluctuations
Problem 2. Hematologic Status and Eltrombopag Initiation
[managing leukopenia and thrombocytopenia in aplastic anemia]
A 58-year-old female, newly diagnosed with aplastic anemia, began treatment with antithymocyte globulin at a dosage of 3.5mg/kg daily for five days starting on 2024-01-16. Additionally, ciclosporin at 300mg daily, divided into two doses (approximately 6mg/kg), was initiated on 2024-01-22. To manage severe leukopenia, G-CSF (filgrastim) has been administered since 2024-01-20. Due to observed thrombocytopenia episodes with platelet counts below 20K/uL, the concurrent initiation of eltrombopag with standard immunosuppressive therapy (antithymocyte globulin and cyclosporine) can also be considered.
Given the patient’s relatively young age, it might be advisable to assess eligibility and seek a match for allogeneic hematopoietic cell transplantation in advance.
[MedRec]
This is a patient with advanced gastric cancer (pT4aN1M1, signet ring cell type, HER2 3+), status post subtotal gastrectomy with B-I anastomosis and feeding jejunostomy on 2025-02-28. The patient is undergoing Trastuzumab + CapOx chemotherapy, initiated per NCCN gastric cancer guidelines for HER2-positive stage IV disease. Labs as of 2025-03-20 to 2025-03-21 reveal chronic kidney disease (eGFR 37.92 mL/min/1.73m²), mild normocytic anemia (HGB 11.3 g/dL), hypokalemia (K 3.4 mmol/L), hypoalbuminemia (albumin 3.4 g/dL), and elevated CA125 (57.2 U/mL). Vitals are stable. Serologies show past HBV infection with high anti-HBs titer.
Problem 1. Advanced Gastric Cancer (pT4aN1M1, HER2+)
Problem 2. Chronic Kidney Disease (CKD, eGFR ~38)
Problem 3. Normocytic Anemia (HGB 11.3 g/dL)
Problem 4. Electrolyte Imbalance: Hypokalemia (K 3.4 mmol/L) (not posted)
Problem 5. Nutritional Risk and Hypoalbuminemia (Albumin 3.4 g/dL) (not posted)
Problem 6. HBV Carrier Status with Immunity
[exam finding]
[MedRec]
[consultation]
[exam finding]
[MedRec]
s no fever, erythema, or wounds formation on the Lt
leg, and no dyspnea, orthopnea or legs edema. After well explain the
indication/procedure/risk to patient/family. She was admitted to our CV
ward for scheduled endovascular treatment to remove IVC filter. [surgical operation]
[chemotherapy]
The patient is a case of advanced ovarian cancer with peritoneal carcinomatosis, undergoing paclitaxel-carboplatin chemotherapy, and experiencing worsening anemia, persistent hypoalbuminemia, electrolyte imbalances, and possible disease progression (CA-125 elevation). The major concerns include severe anemia, ongoing myelosuppression, chronic malnutrition, and potential chemotherapy-associated complications.
Problem 1. Anemia
Objective (Findings & Trends)
Assessment
Recommendations
Problem 2. Hypoalbuminemia and Malnutrition
Objective (Findings & Trends)
Assessment
Recommendations
Problem 3. Electrolyte Imbalances (Hyponatremia, Hypocalcemia)
Objective (Findings & Trends)
Assessment
Recommendations
Problem 4. Possible Disease Progression (CA-125 Elevation & Persistent Ascites)
Objective (Findings & Trends)
Assessment
Recommendations
[Anemia] (since last review on 2025-01-14)
Objective (Findings and Trends)
Assessment (Analysis and Progression)
Current Status: Persistent moderate-severe anemia (HGB 7.2 g/dL, 2025-02-20), slightly improved from 6.6 g/dL (2025-01-14) but still declining compared to 8.7 g/dL (2025-01-16).
Likely Causes:
Disease Trend:
Recommendations (Next Steps)
Conclusion (not posted)
[Summary]
The patient is a 56-year-old female with a history of left ovarian clear cell carcinoma (pT2bN0M0, FIGO Stage IIB, diagnosed 2024-09-06). She has undergone debulking surgery (2024-09-06), developed complications including deep vein thrombosis (DVT) (2024-08-29) with subsequent IVC filter placement and removal (2024-09-05, 2024-10-08), and currently faces recurrent malignant ascites with evidence of metastatic peritoneal involvement. She is undergoing chemotherapy with paclitaxel and carboplatin (most recent administration 2025-01-15). The patient’s active medications address her chemotherapy regimen, anticoagulation, and symptom management.
[Problems]
Problem 1. Recurrent Malignant Ascites
Problem 2. Anemia
Problem 3. Deep Vein Thrombosis and Anticoagulation
[exam finding]
Differential Diagnosis (Descending Probability)
Additional Tests for Diagnosis
Final Thoughts
Next immediate step: Lymph node biopsy and bone marrow aspiration + flow cytometry.
[exam finding]
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
2025-03-03 - Padcev (enfortumab vedotin) 60mg NS 100mL 1hr (C1D8)
2025-02-21 - Keytruda (pembrolizumab) 200mg NS 100mL 1hr + Padcev (enfortumab vedotin) 60mg NS 100mL 1hr (C1D1)
Patient: 88-year-old female
Chief Concern: Follow-up on Keytruda (pembrolizumab) + Padcev
(enfortumab vedotin) therapy, adverse reactions (skin toxicity), renal
function, and medication compliance.
[Subjective]
[Objective]
[Assessment]
[Plan / Recommendation]
Patient: 88-year-old female
Chief Concern: Follow-up on Keytruda (pembrolizumab) + Padcev
(enfortumab vedotin) initiation, adverse effects, and medication
compliance.
Subjective (S)
Objective (O)
Assessment (A)
Plan (P) - Recommendation
Patient Summary
This 88-year-old female has high-grade urothelial carcinoma (UC) of the right kidney, cT3N1M0, stage IV with renal parenchymal invasion (biopsy 2025-01-16) and suspected bladder seeding (CT 2025-01-03). Given PD-L1 negativity (CPS 0%, 2025-01-22) and CKD stage 3b, treatment options are limited.
She also has acute decompensated heart failure (LVEF 37%, pulmonary edema, NYHA IV) (CXR 2025-02-03, echo 2025-02-04), chronic kidney disease (eGFR 39.67 mL/min/1.73m², 2025-02-06), and iron deficiency anemia (Hgb 9.9 g/dL, 2025-02-06). Recent hospitalization (2025-02-02 to 2025-02-06) was due to pulmonary edema secondary to ADHF and aspiration pneumonia, which improved with diuretics (furosemide, spironolactone) and empiric antibiotics (Brosym).
Problem 1. High-Grade Urothelial Carcinoma of the Right Kidney (cT3N1M0, Stage IV)
Problem 2. Chronic Kidney Disease (CKD) Stage 3b with Progressive Renal Impairment
Problem 3. Acute Decompensated Heart Failure (ADHF) with Pulmonary Edema
Problem 4. Iron Deficiency Anemia
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
[Subjective]
[Objective]
Current Medications (Requiring Skin Toxicity Consideration)
Recent Skin-Related Issues
Relevant Labs
[Assessment]
[Plan / Recommendation]
Immediate Actions
Medication Adjustments
Supportive Care
Follow-Up
[MedRec]
{marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)}
[exam finding] (not completed)
[surgical operation]
[immunochemotherapy]
COPD is listed as one of the diagnoses (but not in current problem list) in this hospitalization, however no corresponding medication prescribed yet.
Some bronchodilators such as beta agonists, antimuscarinic agents, or methylxanthines might be considered later after other acute symptoms mitigated.
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
Patient Evaluation
Problem 1. Diffuse Large B-Cell Lymphoma (DLBCL), Non-GCB Subtype
Problem 2. Chemotherapy-Induced Myelosuppression (below not posted)
Problem 3. Cardiovascular Risk & LV Dysfunction
Problem 4. Thrombotic Risk
Problem 5. Splenic Involvement & Possible Autoimmune Cytopenia
Problem 6. Electrolyte & Metabolic Balance
Problem 7. Helicobacter Pylori-Associated Gastritis & Esophagitis
Conclusion
[exam finding]
[MedRec]
[immunochemotherapy]
Updated Insights on Prioritized Issues Since 2024-12-16
Problem 1. Diffuse Large B-Cell Lymphoma (DLBCL) – Treatment Response and Disease Monitoring
Problem 2. Bone Marrow Suppression – Post-Chemotherapy Cytopenias
Problem 3. Glycemic Control – Diabetes Mellitus
Problem 4. Hypertension – Blood Pressure Fluctuations
Problem 5. Thyroid Nodules – Multinodular Goiter
Summary of Prioritized Actions
[Key Summary]
The patient is an 81-year-old female with diffuse large B-cell lymphoma (non-GCB, triple expressor), Lugano stage IV, involving intra-abdominal nodes, left psoas muscle, and rectum. She also has significant comorbidities:
Currently, she is undergoing chemotherapy with polatuzumab vedotin + rituximab + cyclophosphamide + liposomal doxorubicin + prednisolone (Pola-R-CHP). Glycemic control is managed using NovoRapid (insulin aspart) and Tresiba (insulin degludec).
[Problem-Oriented Comments]
[Medication Review]
Active medication:
Summary Recommendations:
[lab data]
2025-01-09 CA-153 (NM) 40.890 U/ml
2024-10-11 CA-153 (NM) 37.080 U/ml
2024-07-16 CA-153 (NM) 36.234 U/ml
2024-04-26 CA-153 (NM) 47.504 U/ml
2024-02-02 CA-153 (NM) 48.501 U/ml
2023-10-27 CA-153 (NM) 61.014 U/ml
2023-07-28 CA-153 (NM) 198.695 U/ml
2023-05-05 CA-153 (NM) 136.84 U/ml
2023-02-02 CA-153 (NM) 69.817 U/ml
2022-09-01 CA-153 20.2 U/mL
2025-01-09 CEA (NM) 3.040 ng/ml
2025-01-08 CEA 2.99 ng/mL
2024-10-11 CEA (NM) 3.265 ng/ml
2024-08-28 CEA 2.20 ng/mL
2024-07-16 CEA (NM) 2.034 ng/ml
2024-05-06 CEA 2.07 ng/mL
2024-04-26 CEA (NM) 2.802 ng/ml
2024-02-02 CEA (NM) 3.276 ng/ml
2024-01-09 CEA 3.49 ng/mL
2023-11-10 CEA (NM) 10.493 ng/ml
2023-10-27 CEA (NM) 9.586 ng/ml
2023-09-19 CEA 5.58 ng/mL
2023-08-31 CEA 6.96 ng/mL
2023-07-28 CEA (NM) 4.836 ng/ml
2023-05-05 CEA (NM) 3.375 ng/ml
2023-02-02 CEA (NM) 2.845 ng/ml
2022-09-01 CEA 4.25 ng/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunichemotherapy]
2025-03-12 - Avastin (bevacizumab) 500mg NS 250mL 90min
2025-01-10 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2025-01-09 - Tecentriq (atezolizumab) 1200mg NS 250mL 60min
2025-01-08 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-12-05 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-12-04 - Rybrevant (amivantamab) 350mg NS 243mL 12hr
2024-12-03 - Avastin (bevacizumab) 500mg NS 250mL 90min + Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-10-15 - Rybrevant (amivantamab) 350mg NS 243mL 12hr
2024-10-14 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-10-11 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-08-29 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-08-28 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-08-27 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-07-10 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-07-09 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-07-08 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-05-08 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-05-07 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-05-06 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-03-06 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-03-05 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-03-04 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-01-10 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-01-09 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-01-08 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-12-13 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2023-12-12 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-12-11 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-11-10 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-11-09 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-09-19 - Avastin (bevacizumab) 500mg NS 250mL 90min + Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-09-01 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-08-31 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-09-14 ~ 2024-01-29 - Tepmetko (tepotinib 225mg) 2# QDCC
2022-10-19 ~ undergoing - Femara (letrozole 2.5mg) 1# QD
[Hypokalemia (K 2.3 mmol/L on 2025-03-12)]
Objective:
Assessment:
Recommendation:
[Progressive Lower Leg Skin Lesions with Exudate] (not posted)
2025-03-17 bedside visit at around 13:30 for leg lesion. Patient resting, inquired with the primary nurse on duty. She showed the images of patient’s red lesions with exudate mainly located on the mid-calf of both legs, mostly about the size of a one to fifty TWD coin. On the left knee, there is a larger area. According to the primary nurse, the patient’s condition has been gradually worsening recently.
Objective:
Assessment:
Recommendation:
[exam finding]
2024-08-02 HBsAg Nonreactive
2024-08-02 HBsAg Value 0.42 S/CO
2024-08-02 Anti-HCV Nonreactive
2024-08-02 Anti-HCV Value 0.78 S/CO
2024-08-02 Anti-HBc Reactive
2024-08-02 Anti-HBc-Value 1.89 S/CO
2024-08-02 Anti-HBc IgM Nonreactive
2024-08-02 Anti-HBc IgM Value 0.08 S/CO
2024-08-02 Anti-HBs 18.11 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Patient Evaluation
Since the last review on 2025-02-19, the patient has received an additional cycle of FOLFOX (2025-02-18, 2025-03-14) and has undergone serial laboratory tests and imaging studies. Major trends include:
Problem #1: Chronic Kidney Disease (CKD Stage 3) – Improving
Problem #2: Progressive Anemia
Problem #3: Hypertension
Since the last review on 2025-01-15, the patient’s clinical course has demonstrated:
Problem #1: Worsening Chronic Kidney Disease (Stage III)
Problem #2: New or Progressive Pleural Effusion
Problem #3: Worsening Anemia
Problem #4: Hypertension with Wide Variability
Problem #5: Dermatological Concern - Scalp Lesion (Furuncle vs. Skin Metastasis)
[Summary]
The patient is an 81-year-old male with a complex medical history, including:
Key current issues include anemia, leukopenia, renal dysfunction, and management of malignancy. Recent imaging and lab findings reflect disease stability but ongoing treatment-related challenges.
[Problems]
Problem #1: Chronic Kidney Disease (CKD) - Stage III
Problem #2: Gastrointestinal Malignancy - Sigmoid Adenocarcinoma
Problem #3: Anemia
Problem #4: Immune Status
Problem #5: Cardiovascular Health and Atherosclerosis
Problem #6: Dermatological Concern - Furuncle with Differential Diagnosis of Skin Metastasis
[gradual FOLFOX dose increase maintains renal stability, dapagliflozin dosing guidelines for CKD patients]
FOLFOX was administered at 50% of the standard dose on 2024-08-07 and 60% on 2024-08-29. With this gradual dose increase, serum creatinine has remained around 2 mg/dL, and eGFR has stayed approximately at 30, indicating stable renal function.
Additionally, for patients with CKD and an eGFR below 25, it is recommended that Forxiga (dapagliflozin) not exceed a daily dose of 10 mg.
2024-08-29 Creatinine 1.99 mg/dL
2024-08-09 Creatinine 2.02 mg/dL
2024-08-07 Creatinine 2.27 mg/dL
2024-08-01 Creatinine 1.99 mg/dL
2024-08-29 eGFR 34.63 ml/min/1.73m^2
2024-08-09 eGFR 34.03 ml/min/1.73m^2
2024-08-07 eGFR 29.75 ml/min/1.73m^2
2024-08-01 eGFR 34.63 ml/min/1.73m^2
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Evaluation of Deferasirox for Iron Overload]
Indication & Justification:
Contraindications Review - Deferasirox is contraindicated in:
Recommendation:
[Patient Review]
Reevaluation of Issues Since Last Review (2025-01-22 → 2025-03-13)
Problem 1. Persistent Anemia with Thrombocytopenia
Problem 2. Renal Function Fluctuations (below not posted)
Problem 3. Persistent Inflammation / Infection Concern
Problem 4. Ongoing GI Bleeding Concern
Problem 5. Bilateral Pleural Effusions
Problem 6. Persistent Pancreatic Enzyme Elevation
Conclusion
[Candida glabrata treatment]
The urine culture sampled on 2025-01-17 revealed Candida glabrata with a colony count of 1,000 CFU/mL.
Candida glabrata treatment in adults with normal kidney function.
If fluconazole is selected, a dosage of 50 to 200 mg once daily (QD) can be considered based on the eGFR of 31.52 recorded on 2025-01-20.
[Summary]
Problem 1. Hematological Abnormalities
Problem 2. Pleural Effusion and Suspected Respiratory Compromise
Problem 3. Candida Glabrata in Urine Culture
Problem 4. Renal Function Decline
Problem 5. Poor Glycemic Control
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[immunochemotherapy]
2025-03-12 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3260mg NS 500mL 46hr (Erbitux + FOLFIRI. Iri 50%, FV 70%)
2025-02-20 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI 70%)
2024-12-20 - [leucovorin 20mg/m2 21mg NS 100mL 30min + fluorouracil 425mg/m2 560mg NS 100mL 10min] D1,3-6 (bolus 5-FU 70%, CCRT)
2024-12-06 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 195mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2370mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-11-19 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 195mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2360mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-10-25 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 195mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2350mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-09-30 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 190mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2350mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-09-09 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 160mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 200mg/m2 260mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3100mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
2024-08-15 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 160mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 200mg/m2 250mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3090mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
2024-07-26 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 150mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 68mg D5W 250mL 2hr + leucovorin 200mg/m2 250mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3075mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
2024-07-09 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 100mg D5W 250mL 1.5hr + oxaliplatin 50mg/m2 68mg D5W 250mL 2hr + leucovorin 200mg/m2 240mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3000mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 40%, Oxalip 40%, LV 80%, 5FU 80%)
2024-06-19 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 130mg/m2 100mg D5W 250mL 1.5hr + oxaliplatin 50mg/m2 67mg D5W 250mL 2hr + leucovorin 200mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%)
2024-05-31 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 400mg/m2 600mg D5W 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino 60%)
2024-05-15 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 170mg D5W 250mL 1.5hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 400mg/m2 600mg D5W 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino 60%)
2024-04-25 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 140mg D5W 250mL 1.5hr + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 400mg/m2 310mg NS 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino ?off)
2024-04-11 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 140mg D5W 250mL 1.5hr + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 400mg/m2 310mg NS 10min + fluorouracil 2400mg/m2 1900mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino ?off)
Patient Evaluation
Problem 1. Metastatic Ascending Colon Adenocarcinoma (cT4aN2bM1a, Stage IVA, BRAF V600E)
Problem 2. Chronic Viral Hepatitis B
Problem 3. Lumbar Spondylosis with Severe Central Canal Stenosis
Problem 4. Ventral Hernia with Bowel Loop Herniation
Problem 5. Chemotherapy-Related Gastrointestinal and Hematologic Toxicities
Conclusion (not posted)
[exam finding]
[MedRec]
[consultation]
Post-NSTEMI, Post-PCI
[Subjective]
Chief Complaint (CC):
Current Symptoms:
Medication Adherence & Understanding:
[Objective]
Vital Signs (2025-03-12):
Physical Examination:
Laboratory Data (2025-03-07, recent reference):
Current Medications (repeat 28-day supply, as per cardiology visit 2025-03-12):
[Assessment]
Post-NSTEMI, Post-PCI with DES (2025-03-04), Now Stable
DAPT Adherence Confirmed & Reinforced
Statin Therapy is Suboptimal for Secondary Prevention
ACEI Preferred Over ARB for Post-MI Mortality Reduction
[Plan, Recommendation]
Continue DAPT (Aspirin + Ticagrelor) with Emphasis on Adherence
Statin Optimization for LDL Goal <55 mg/dL
Assess Need for Long-Term PPI Use
Follow-up & Monitoring
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 82-year-old male has relapsed small B-cell lymphoma with plasma cell differentiation (Stage IV), currently undergoing R-COP chemotherapy (C1 on 2025-02-14, C2 on 2025-03-10). The disease involves multiple lymph node regions and the bone marrow (PET 2025-02-14, BM biopsy 2025-01-10).
His recent clinical course has been complicated by worsening anemia (Hgb 10.5 g/dL on 2025-03-10 vs. 11.4 g/dL on 2025-02-21), persistent hypoalbuminemia (2.5 g/dL on 2025-03-10 vs. 1.8 g/dL on 2025-02-10), and hyponatremia (Na 129 mmol/L on 2025-03-10, 125 mmol/L on 2025-02-10). Hypergammaglobulinemia (IgG 9021 mg/dL on 2024-12-28) suggests an active monoclonal gammopathy, possibly Waldenström macroglobulinemia (WM) or lymphoplasmacytic lymphoma (LPL).
Other comorbidities include hypertension, diabetes mellitus with triopathy, asthma, reflux esophagitis, and benign prostatic hyperplasia.
Problem 1. Relapsed Small B-Cell Lymphoma (Stage IV)
Problem 2. Worsening Anemia
Problem 3. Persistent Hypoalbuminemia
Problem 4. Hyponatremia
Problem 5. Hyperuricemia
Problem 6. Benign Prostatic Hyperplasia (BPH)
Plan Summary
[Interpretation of Bone Marrow Biopsy Diagnosis] (not posted)
Diagnosis: Small B-cell lymphoma with plasma cell differentiation
Objective Findings
Assessment & Interpretation
Recommendation
Final Interpretation:
[Interpretation of Bone Marrow Biopsy Diagnosis] (posted)
Diagnosis: Small B-cell lymphoma with plasma cell differentiation
Objective Findings
Assessment & Interpretation
Recommendations
Final Interpretation
[exam finding]
[MedRec]
2025-03-07 ~ 2025-03-09 POMR Hemato-Oncology Xia HeXiong
2025-02-25 SOAP Hemato-Oncology Xia HeXiong
2025-02-18 SOAP Hemato-Oncology Xia HeXiong
2025-02-03 SOAP Colorectal Surgery Xiao GuangHong
2023-03-05 ~ 2023-03-10 POMR Integrative Medicine Rao LunYu
2022-11-01 ~ 2022-11-02 POMR Colorectal Surgery Xiao GuangHong
2020-07-27 ~ 2020-08-03 POMR Neurology Dai BoAn
2020-06-25 ~ 2020-06-26 POMR Urology Xu JunKai
[surgical operation]
[chemotherapy]
[exam finding] (not completed)
[MedRec] (not completed)
[immunochemotherapy]
[lab data]
2024-03-13 HBV-DNA-PCR 110000 IU/mL
2024-03-11 Anti-HBs 5.31 mIU/mL
2024-03-11 Anti-HBc Reactive
2024-03-11 Anti-HBc Value 6.06 S/CO
2024-03-11 Anti-HBe Reactive
2024-03-11 Anti-HBe Ratio 0.26 S/CO
2024-03-11 HBsAg Reactive
2024-03-11 HBsAg Value 348.93 S/CO
2024-03-11 Anti-HCV Nonreactive
2024-03-11 Anti-HCV Value 0.06 S/CO
2024-03-11 HIV Ab-EIA Nonreactive
2024-03-11 Anti-HIV Value 0.04 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Since the last review on 2025-02-26, the patient’s condition has shown notable changes, particularly in renal function, hematologic parameters, fluid balance, and respiratory status. The following key points summarize the latest trends:
Problem 1. Worsening Renal Function with Volume Overload
Problem 2. Persistent Infection and Pneumonia (below not posted)
Problem 3. Persistent Anemia and Thrombocytopenia
Problem 4. Electrolyte Imbalances (Na, K, Ca)
Final Plan Summary
This 85-year-old woman with recurrent diffuse large B-cell lymphoma (DLBCL), non-GCB subtype, Lugano stage IV, Ki-67 95%, IPI score 5, presents with ECOG PS 4, chronic comorbidities including hypertension, type 2 diabetes mellitus, chronic atrial fibrillation, prior left MCA infarction with right hemiparesis, and recent pneumonia over the right lung.
Key concerns from recent studies:
Problem 1. Right Lung Pneumonia
Problem 2. Recurrent Diffuse Large B-Cell Lymphoma (DLBCL) Progression
Problem 3. Cytopenia (Anemia & Thrombocytopenia)
Problem 4. Catheter-Associated Bloodstream Infection (E. coli Bacteremia, Port-A Removed 2025-02-24)
Problem 5. Rapid Weight Gain with Generalized Edema
Problem 6. Worsening Renal Function (Possible AKI)
[assessing blood counts post R-CHOP treatment]
Lab results on 2024-08-19 were generally normal. However, records indicate that neutropenia (nadir) was observed approximately two weeks after the first day of R-CHOP administration. Continued monitoring of blood cell counts is recommended to determine if G-CSF is needed.
[not meeting ANC threshold for R-CHOP]
WBC lab data:
ANC = (60.2% + 1.0%) / 100 * 2.15 x 10K/uL = 1.31 x 10K/uL
The generally accepted minimum ANC threshold for administering the R-CHOP regimen is 1,500 cells/μL. It is recommended to delay the treatment until ANC is > 1500/microL and platelet count is > 100K/uL.
[regular LVEF monitoring recommended]
This patient frequently visits the cardiology department at our hospital, with records dating back to 2017. Recent diagnoses include:
On 2024-03-18, a 2D transthoracic echocardiography estimated the LVEF at 64%. Using liposomal doxorubicin instead of conventional doxorubicin can reduce the incidence of cardiomyopathy (though not eliminate all the risk). It is recommended to regularly measure LVEF during treatment to monitor for cardiomyopathy.
[exam findings] (not completed)
[MedRec]
[consultation]
[immunochemotherapy]
[neutropenia follow-up]
Neutropenia resolved after Granocyte (lenograstim) administration for 3 consecutive days beginning on 2024-05-09.
[grade 3 neutropenia developed]
Lab results indicated an ANC of 728/uL. Caution is advised when administering a new session of R-CHOP.
Treatment should ideally be started only after the ANC has risen at least above 1000/uL.
[reconciliation]
Hypocalcemia was observed with a calcium level of 1.87 mmol/L on 2024-04-15, for which a dose of IVD Calglon (calcium gluconate) was administered, followed by a prescription for oral calcium carbonate. All other lab parameters recorded on that date were grossly within normal limits, and there were no discrepancies in medication management.
[immunochemo with graded doxorubicin addition & electrolyte management]
Liposomal doxorubicin was incorporated into the existing immunochemotherapy regimen on a gradual basis. The initial dose of 20mg was administered on 2024-01-29, followed by an escalation to 40mg on 2024-02-19.
Concomitantly, Const-K and calcium carbonate were used to manage hypokalemia (3.2mmol/L) and hypocalcemia (1.99mmol/L), respectively. No medication discrepancies were identified.
[managing low platelet counts during cancer treatment]
Since Dec 2023, this patient has exhibited persistent thrombocytopenia, well before starting the R-COP regimen on 2024-01-03. While R-COP may contribute to this condition, it should not be considered the sole cause. Thrombocytopenia could also be a manifestation of the patient’s underlying DLBCL.
Patients being treated with cytotoxic chemotherapy have a suppressed bone marrow that often cannot produce adequate platelets. It is recommended to use prophylactic platelet transfusion in these settings, assuming the patient is hospitalized, afebrile, and without active infection. A threshold platelet count of 10K/uL (transfuse for a platelet count < 10K/uL) is generally used. If fever, sepsis, or coagulopathy is present, or if the patient is not hospitalized and/or cannot be closely monitored, higher thresholds may be needed. (Ref: https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks)
[lab data]
2024-03-19 Anti-HBc Reactive
2024-03-19 Anti-HBc Value 7.02 S/CO
2024-03-19 Anti-HCV Nonreactive
2024-03-19 Anti-HCV Value 0.11 S/CO
2024-03-19 Anti-HBs 0.00 mIU/mL
2024-03-19 HBsAg Reactive
2024-03-19 HBsAg (Value) 3979.86 S/CO
[exam findings]
2025-02-14 CT - abdomen
2024-11-07 CT - abdomen
2024-09-17 KUB
2024-08-27 2D transthoracic echocardiography
2024-08-08 CT - abdomen
2024-07-27 ECG
2024-07-05 ECG
2024-05-22 SONO - abdomen
2024-05-21 ECG
2024-05-05 CXR erect
2024-05-05 ECG
2024-04-30 2D transthoracic echocardiography
2024-03-26 CT - abdomen
2024-03-22 2D transthoracic echocardiography
2024-01-24 T-tube cholangiography
2024-01-13 ECG
2024-01-11 CTA - chest
2024-01-08 CT - abdomen
2023-12-29 Patho - pancreas total/subtatal resection
2023-12-22 Patho - pancreas total/subtatal resection
2023-12-04 Cardiac Catheterization
2023-11-30 Myocardial perfusion SPECT with persantin
2023-11-28 2D transthoracic echocardiography
2023-11-24 Flow Volume Chart
2023-11-23 MRI - liver, spleen
2023-11-22 Patho - pancreas biopsy
2023-11-21 PTCD drainage
2023-11-20 CT - abdomen
2023-11-17 CT - abdomen
2023-11-16 SONO - abdomen
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Analysis of Why the Chemotherapy Regimen Changed]
The most recent chemotherapy regimen was changed on 2025-03-07 from pembrolizumab + mFOLFIRINOX (administered on 2025-02-03) to gemcitabine + nab-paclitaxel + TS-1 (tegafur/gimeracil/oteracil) + folinate.
Objective: Evidence of Treatment Failure or Disease Progression
Assessment: Rationale for Switching to Gemcitabine-Based Therapy
Recommendation: Future Considerations
[Summary]
The patient has advanced pancreatic ductal adenocarcinoma, status post Whipple operation on 2023-12-21, followed by adjuvant chemotherapy (mFOLFIRINOX started on 2024-03-18 with pembrolizumab since 2024-09-11).
Rising tumor marker CA199 (from 71.85 U/mL on 2024-09-25 to 172.71 U/mL on 2024-12-19) and imaging findings suggest possible progression of disease.
Comorbidities include type 2 diabetes mellitus with variable glycemic control, chronic kidney disease (Stage 3), and hypertension.
Lab results indicate normocytic anemia (HGB 9.7 g/dL on 2024-12-26), hypoalbuminemia (albumin 3.3 g/dL on 2024-12-26), and a history of coronary artery disease with LAD stenosis (2023-12-04 Cardiac Catheterization).
[Problems]
Tumor Progression and Chemotherapy Response
Anemia and Nutritional Deficiency
Hypertension and Coronary Artery Disease
Diabetes and Glycemic Control
[Medication Review]
Medication Appropriateness
Key Observations
[poor glycemic control: insulin initiated]
Lab results indicated poorly controlled blood sugar levels. Insulin injections have been newly initiated to address this issue.
If blood glucose levels remain above 200mg/dL for two consecutive days, increasing the insulin dosage or adding oral oral antiglycemic agents may be necessary.
[optimizing insulin dosing for high fasting glucose levels]
On 2024-05-05, a chest X-ray revealed a solitary pulmonary nodule in the RUL and ground-glass opacity in the LLL, with a CRP level of 3.9 mg/dL, suggesting an infection, currently managed with Brosym (cefoperazone, sulbactam).
The patient is on basal insulin therapy of 10 units at bedtime and bolus insulin before meals - 4 units for breakfast, 5 units for lunch, and 5 units for dinner. Despite this regimen, fasting serum glucose was recorded at 327 mg/dL on 2024-05-07 at 11:42. If such elevated levels persist, an increase in the insulin dosage should be considered.
[new-onset diabetes after pancreas surgery, potassium level for insulin user]
Approximately 16.6% of patients may develop diabetes following pancreaticoduodenectomy, with preoperative glycated hemoglobin levels above 5.4% being a predictor of new-onset diabetes. (https://doi.org/10.1016/j.jamcollsurg.2018.12.042)
The development of diabetic ketoacidosis (DKA) involves both a deficiency of insulin and an excess of glucagon, with glucagon playing a contributing but not essential role.
Insulin is a potent stimulus for hypokalaemia, sparing body potassium from urinary excretion by transporting it into cells. Given that the patient’s serum potassium was normal three days ago on 2024-03-25 and the patient is currently using insulin, it’s advisable to update the potassium level to determine the need for potassium supplementation.
[fluctuating hyperglycemia: consider increasing basal insulin]
The patient’s blood sugar levels are elevated and fluctuating, as shown by readings of 217, 181, and 361. If these high levels continue, it is recommended to increase the basal insulin dosage by 2 units.
[exam finding]
[consultation]
[radiotherapy]
[immunochemotherapy]
[note]
Atezolizumab - 2025-03-10 - https://www.uptodate.com/contents/atezolizumab-drug-information
Evaluation for the Second Administration of Tecentriq (atezolizumab)
Key Considerations for Tecentriq (atezolizumab) Administration
Tecentriq (atezolizumab) is an immune checkpoint inhibitor that can cause immune-mediated toxicities, particularly hepatotoxicity. Given the patient’s history of hepatocellular carcinoma (HCC) with portal vein thrombosis, cirrhosis, and prior liver-directed therapies (RFA, TACE, and RT), close evaluation of hepatic function, immune-related adverse events, and overall performance status is essential before proceeding with the second session.
Assessment
A. Hepatic Function
Atezolizumab requires careful consideration in patients with hepatic impairment. Liver function tests (LFTs) on 2025-03-08 reveal:
Interpretation:
Monitoring Plan:
B. Renal Function
C. Hematologic Function
D. Electrolyte Abnormalities
Monitoring Plan:
Overall Assessment and Recommendation
Recommendation:
Reassessment Timeline:
At present, Tecentriq administration is NOT recommended until further evaluation.
[exam finding]
[chemotherapy]
[exam finding]
Diagnosis: 1. Ovary, right, Staging surgery— serous carcinoma, high-grade 2. Ovary, left, Staging surgery— negative for malignancy 3. Fallopian tube, right, Staging surgery— involved by serous carcinoma 4. Fallopian tube, left, Staging surgery— negative for malignancy 5. Myometrium, Staging surgery— suberosal and intramural myomas 6. Endometrium, Staging surgery— negative for malignancy 7. Cervix, Staging surgery— negative for malignancy 8. Lymph node, left iliac, dissection— metastatic carcinoma (1/6) 8. Lymph node, left obturator, dissection— negative formalignancy (0/5) 9. Lymph node, right iliac, dissection— negative formalignancy (0/11) 10. Lymph node, right obturator, dissection— negative formalignancy (0/6) 11. Lymph node, left paraaortic, dissection— metastatic carcinoma (1/3) 12. Lymph node, right paraaortic, dissection— negative formalignancy (0/3) 13. Omentum, Staging surgery— negative formalignancy 1 AJCC 8th edition pathology stage: pT2aN1a(if cM0); FIGO Stage IIIA1i
Gross description: 1. Procedure (select all that apply) Staging surgery (ATH + BSO + Bilateral pelvic and paraaortic lymph nodes dissection + infracolic omentectomy ) Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
Specimen size: Ovary, right: 10x8x5 cm Ovary, left: 2.5x2x1 cm Fallopian tube, right: 5 cm in length Fallopian tube, left: 5 cm in length Uterus: 9x6x4 cm Omentum: 43x11x1.3 cm
Specimen Integrity [NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.]
Sections are taken and labeled as:F2024-550A1-7:right ovarina tumor, F2024-550A8:right tube, S2024-26539A1:left iliac LN, A2:left obturator LN, A3-4:right iliac LN, A5: right obturator LN, A6:left paraaortic LN, A7:right paraaortic LN, A8:cx, A9-11:corpus uteri, A12-13:left adnexae, A14:omentum
Microscopic Description: 1. Histologic Type: High-grade serous carcinoma
Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors) (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.) Not applicable
Implants (required for advanced stage serous/seromucinous borderline tumors only) (Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.) Not applicable
Other Tissue/ Organ Involvement: Right fallopian tube
Largest Extrapelvic Peritoneal Focus: Not applicable
Peritoneal/Ascitic Fluid: Suspicious malignancy (N2024-04776)
Regional Lymph Nodes: Left iliac– 1/6 Left obturator— 0/5 Rght iliac— 0/11 Right obturato— 0/6 Left paraaortic— 1/3 (< 10 mm) Right paraaortic 0/3
Additional Pathologic Findings: suberosal and intramural myomas
Comment(s): none
Immunohistochemical stains: p53:aberrant(diffuse, strong staining, >90%), WT-1(+), Napsin A(-), vimentin(-), CK20(-)
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 54-year-old female with high-grade serous carcinoma of the right ovary (pT2aN1a, FIGO Stage IIIA1i) s/p optimal debulking surgery (ATH + BSO + bilateral pelvic and paraaortic lymph node dissection + infracolic omentectomy on 2024-12-18), currently undergoing adjuvant chemotherapy with paclitaxel + carboplatin (latest cycle on 2025-03-06).
Her disease initially presented with abdominal fullness, pain, and massive ascites (CT 2024-12-13), with ascitic cytology suspicious for malignancy (2024-12-16, 2024-12-19). Histopathology confirmed high-grade serous carcinoma with lymph node metastasis (L iliac 1/6, L paraaortic 1/3) and peritoneal involvement (right fallopian tube, ascitic fluid positive).
Current concerns include:
Problem 1. Ovarian Cancer (High-Grade Serous Carcinoma, FIGO Stage IIIA1i, s/p Debulking Surgery)
Problem 2. Chemotherapy-Induced Hematologic Changes
Problem 3. Renal Function and Chemotherapy-Related Nephrotoxicity
Problem 4. Tumor Marker Trends and Disease Monitoring
Problem 5. ENT Concerns – Chronic Tinnitus and Eustachian Tube Dysfunction
Final Plan
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Since the last review on 2025-01-22, the patient has continued on chemotherapy with Bevacizumab (bevacizumab), Paclitaxel (paclitaxel), and Carboplatin (carboplatin) at non-regular intervals (C1 2024-10-01, C2 on 2024-11-04, C3 on 2024-11-29, C4 on 2024-12-25, C5 on 2025-01-21, C6 on 2025-03-05). The following notable updates are observed:
Problem 1. Ongoing Management of High-Grade Serous Carcinoma
Problem 2. Mild Anemia and Hematologic Recovery
Problem 3. Renal and Hepatic Function Stability
Problem 4. Persistent Microscopic Hematuria and Renal Tubular Cells in Urinalysis
Final Summary of Updates and Plan Since 2025-01-22 → 2025-03-05
| Category | Previous (2025-01-22) | Latest (2025-03-05) | Change |
|---|---|---|---|
| CA-125 (U/mL) | 6.120 (2025-01-23) | 7.900 (2025-01-09) | Stable |
| HGB (g/dL) | 11.1 (2025-01-27) | 11.5 (2025-03-04) | Slightly Improved |
| PLT (x10³/uL) | 122 (2025-01-27) | 182 (2025-03-04) | Significant Increase |
| WBC (x10³/uL) | 3.39 (2025-01-27) | 5.25 (2025-03-04) | Improved |
| Creatinine (mg/dL) | 0.44 | 0.40 | Improved |
| eGFR (mL/min/1.73m²) | 160.87 | 179.58 | Improved |
| BP (mmHg) | Normal | 160/107 (2025-03-04) | Elevated |
| Microscopic Hematuria | Absent | 3-5 RBC/HPF, RTE cells 1-5/HPF | New Finding |
Next Steps:
This patient has a history of high-grade serous carcinoma of the ovary, FIGO Stage IIA, diagnosed on 2024-08-29 (pathology report, 2024-08-29), treated with debulking surgery and subsequent cycles of Taxol (paclitaxel) + Carboplatin, with the addition of Avastin (bevacizumab) from 2024-11-04. Serial CA-125 tumor marker levels have shown improvement (477.2 U/mL on 2024-08-26 to 7.9 U/mL on 2025-01-09), suggesting treatment efficacy. Imaging studies suggest persistent omental tumor seeding (CT, 2024-12-09).
However, notable issues include:
Problem 1. Persistent Omental Lesions
Problem 2. Hematologic Trends (Anemia and Leukopenia)
Problem 3. Nutritional and Electrolyte Status (not posted)
Summary of Further Actions
Supplementary Considerations
The treatment pathway (surgery, chemotherapy, maintenance, and follow-up) adheres to NCCN recommendations for Stage IIA high-grade serous carcinoma. Genetic testing is recommended to be reviewed or considered if not performed to evaluate potential benefits from PARP inhibitors.
[role of bevacizumab and PARP inhibitors in advanced ovarian cancer care]
Pathology and Staging:
Current Treatment:
Systemic Therapy:
Maintenance Therapy Consideration:
Follow-Up and Monitoring:
Additional Recommendations:
Pathology and Staging:
Current Treatment:
Systemic Therapy:
Maintenance Therapy Consideration:
Follow-Up and Monitoring:
Recommendations for Consideration
[lab data]
2024-09-24 HBsAg Nonreactive
2024-09-24 HBsAg Value 0.33 S/CO
2024-09-24 Anti-HBc Reactive
2024-09-24 Anti-HBc Value 5.02 S/CO
2024-09-24 Anti-HCV Nonreactive
2024-09-24 Anti-HCV Value 0.19 S/CO
[exam findings]
[consultation]
[immunochemotherapy]
Patient Summary
Problem 1. Extranodal Marginal Zone Lymphoma (Left Lacrimal Gland) Under R-COP Therapy
Problem 2. Atrial Fibrillation with Valvular Disease and Pulmonary Hypertension (below not posted)
Problem 3. Persistent Mild Anemia (Likely Chemotherapy-Induced or Chronic Disease-Related)
Problem 4. History of Suspected Laryngeal Cancer (Later Found to Be Reactive Lymphoid Hyperplasia)
Conclusion
[monitoring WBC in follow-up to R-COP treatment]
Mild hypokalemia has been observed, which might be managed through potassium supplementation via tablets or diet.
Following the R-COP regimen on 2024-09-23, mild leukopenia was noted on 2024-10-04. It is recommended to continue monitoring WBC changes after the second session administered this hospitalization.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-03-03 - ………………………………….. irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg 500mL 46hr (FOLFIRI. hold Avastin due to colostomy has dark blood noted)
2025-01-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg 500mL 46hr (Avastin + FOLFIRI)
2024-12-24 - (Avastin + FOLFIRI)
2024-11-27 - (Avastin + FOLFIRI)
2024-11-08 - (Avastin + FOLFIRI)
2024-10-08 - (Avastin + FOLFIRI)
2024-09-04 - (Avastin + FOLFIRI)
2024-08-05 - (Avastin + FOLFIRI)
2024-07-15 - (Avastin + FOLFIRI)
2024-06-24 - (Avastin + FOLFIRI)
2024-06-03 - (Avastin + FOLFIRI)
2024-05-20 - (Avastin + FOLFIRI)
2024-04-19 - (Avastin + FOLFIRI)
2024-03-18 - (Avastin + FOLFIRI)
2024-02-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3820mg NS 500mL 46hr (Avastin + FOLFOX)
2024-01-24 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (Avastin + FOLFOX)
2024-01-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3850mg NS 500mL 46hr (Avastin + FOLFOX)
2023-12-06 - (Avastin + FOLFOX)
2023-11-09 - (Avastin + FOLFOX)
2023-10-20 - (Avastin + FOLFOX)
2023-10-04 - (Avastin + FOLFOX)
2023-09-13 - (Avastin + FOLFOX)
2023-08-21 - (Avastin + FOLFOX)
2023-07-28 - (Avastin + FOLFIRI)
2023-07-12 - (Avastin + FOLFIRI)
2023-06-20 - (Avastin + FOLFIRI)
2023-05-30 - (Avastin + FOLFIRI)
2023-05-08 - (FOLFIRI)
On 2024-02-19, the patient received Avastin + FOLFOX during her current hospital stay. Lab values obtained on the same date were unremarkable except for an elevated alkaline phosphatase level at 154 U/L.
A subsequent sigmoidoscopy performed on 2024-02-20 revealed luminal narrowing up to 10cm from the anal verge. This finding suggests rectal stenosis and precluded evaluation of the primary tumor site.
No medication discrepancies were identified during the review.
[lab data]
2024-08-26 FLT3-D835 (BM) Undetectable
2024-08-23 HBsAg Nonreactive
2024-08-23 HBsAg Value 0.42 S/CO
2024-08-23 Anti-HBc Nonreactive
2024-08-23 Anti-HBc-Value 0.23 S/CO
2024-08-23 Anti-HCV Nonreactive
2024-08-23 Anti-HCV Value 0.18 S/CO
2024-08-23 HLA A-high 02:06
2024-08-23 HLA A-high 33:03
2024-08-23 HLA B-high 15:18
2024-08-23 HLA B-high 58:01
2024-08-23 HLA C-high 03:02
2024-08-23 HLA C-high 07:04
2024-08-23 HLA DQ-high 02:01
2024-08-23 HLA DQ-high 05:01
2024-08-23 HLA DR-high 03:01
2024-08-23 HLA DR-high 10:01
2024-08-22 CMV viral load assay Target Not Detected IU/mL
2024-08-22 Mycoplasma IgM Negative Index
2024-08-22 Mycoplasma IgM Value 0.2 Index
2024-08-20 Cryptococcus Ag Negative
2024-08-20 Cold hemo. <1:8
2024-08-20 BCR/abl (BM)(qual) Undetectable
2024-08-16 JAK2 (quan) 0.00 %
2024-08-16 FLT3/ITD (BM) Undetectable
2024-08-16 NPM1 (quan)(BM) Presence of mutation
2024-08-16 P.jiroveci DNA-Sp Undetectable
2024-08-15 CMV viral load assay Target Not Detected IU/mL
2024-08-15 CD2 NA
2024-08-15 CD3 2.8
2024-08-15 CD4 NA
2024-08-15 CD5 0.6
2024-08-15 CD7 0.1
2024-08-15 CD8 NA
2024-08-15 CD10 4.5
2024-08-15 CD11b 34.4
2024-08-15 CD13 96.2
2024-08-15 CD14 0.2
2024-08-15 CD15 NA
2024-08-15 CD16 0.62
2024-08-15 CD19 0.4
2024-08-15 CD19/kappa NA
2024-08-15 CD19/Lambda NA
2024-08-15 CD20 1.08
2024-08-15 CD23 NA
2024-08-15 CD25 NA
2024-08-15 CD33 99.4
2024-08-15 CD34 0.39
2024-08-15 CD38 NA
2024-08-15 CD56 0.06
2024-08-15 CD103 NA
2024-08-15 CD117 97.2
2024-08-15 CD138 NA
2024-08-15 FMC7 NA
2024-08-15 HLA-DR 56.3
2024-08-15 MPO NA
2024-08-15 TdT NA
[exam finding]
[MedRec]
[consultation]
2025-02-10 Infectious Disease
2024-12-24 Colorectal Surgery
2024-10-14 Colorectal Surgery
2024-10-09 Infectious Disease
2024-09-10 Cardiology
….-..-..
[surgical operation]
[chemotherapy]
[Step-by-Step Comprehensive Analysis and Potential Improvements for Future PBSCT Success]
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
Final Conclusion and Future PBSCT Considerations
If PBSCT were attempted again, earlier metabolic intervention and aggressive infectious control might have improved survival.
Since the last review on 2025-02-19 (Day -1 of allo-PBSCT), the patient’s condition has evolved significantly in the post-transplant period. The primary concerns include severe neutropenia with associated infections, worsening gastrointestinal symptoms (severe diarrhea), febrile episodes, hepatic enzyme abnormalities, and worsening anemia and thrombocytopenia.
Problem 1: Post-Allo PBSCT Severe Neutropenia & Engraftment Monitoring
Problem 2: Infection Risk & Persistent Fever
Problem 3: Severe Diarrhea & GI Mucositis
Final Summary
Next Steps:
Liver Function Adjustment Recommendations (source: UpToDate) for Schedule Conditioning Regimen (starting 2025-02-19)
[Child-Pugh Score Assessment - Class A (Score = 5)]
Child-Pugh Score Assessment - Total Child-Pugh Score: 5 points
| Parameter | Measurement | Score Criteria | Score |
|---|---|---|---|
| Total Bilirubin (mg/dL) | 0.49 | <2 mg/dL (1 point) | 1 |
| Serum Albumin (g/dL) | 4.5 | >3.5 g/dL (1 point) | 1 |
| INR | Not available (assumed stable) | <1.7 (1 point) | 1 |
| Ascites | None on exam | None (1 point) | 1 |
| Hepatic Encephalopathy | None observed | None (1 point) | 1 |
Child-Pugh Class and Interpretation
Final Classification:
Considerations:
[Patient Review]
Since the last review on 2025-02-10, the patient has undergone preparative chemotherapy for allogeneic PBSCT using Fludarabine + Busulfan (2025-02-14 to 2025-02-18), followed by Total Body Irradiation (TBI) 200cGy/2 fractions and anti-thymocyte globulin (ATG) (2025-02-18 to 2025-02-19). The patient’s ECOG performance status remains 0, with no fever, no nausea/vomiting, and stable vitals. However, the latest laboratory findings (2025-02-19) reveal significant liver enzyme elevation (ALT 1054 U/L, AST 743 U/L), mild hyponatremia (Na 134 mmol/L), and persistent anemia (Hgb 12.5 g/dL) with a declining platelet count (PLT 125 ×10³/uL from 184 ×10³/uL on 2025-02-14). Three major problems that require priority assessment:
Problem 1. Hepatic Injury (Preparative Regimen-Associated vs. SOS/VOD)
Problem 2. Hematologic Trends (Cytopenia and Myelosuppression Post-Conditioning)
Problem 3. Electrolyte Imbalance (Mild Hyponatremia and Metabolic Risks)
[Patient Evaluation Update with Lab Results (2025-02-19 12:04)]
The patient, currently undergoing haploidentical allogeneic PBSCT for AML (AMMoL, NPM1-mutated), has notable hepatic, infectious, and hematological concerns post-conditioning with Fludarabine + Busulfan + PTCy + TBI + ATG. The most recent labs (2025-02-19 12:04) reveal:
Problem 1: Severe Hepatocellular Injury (Post-Busulfan & TBI)
Problem 2: Suspected Severe Sepsis vs. Cytokine Storm
Problem 3: Post-Transplant Pancytopenia Risk (below not posted)
Summary
[Prevymis (letermovir) Administration & NHI Reimbursement Guidance]
Administration Guidelines for Nurses (according to the package insert)
Prevymis (letermovir) is used for CMV prophylaxis in CMV-seropositive allogeneic HSCT recipients (R⁺). It can be administered orally or via IV infusion. This drug is scheduled for use according to the peritransplantation regimen outlined in the Family Meeting on the afternoon of 2025-02-10.
Oral Route (Preferred)
IV Infusion (If Oral Intake is Not Feasible)
Tube Feeding Considerations
Duration of Use
Important Considerations & Precautions
NHI Reimbursement Guidance for Physicians
To ensure reimbursement, prior approval from the NHI is required.
Eligible Patients:
Usage Restriction:
Action Required:
Summary
Problem 1. Persistent Acute Myelomonocytic Leukemia (AMMoL)
Problem 2. Pre-Transplant Infection Risk
Problem 3. Atrial Fibrillation & Cardiac Considerations
Problem 4. Nutritional and Gastrointestinal Concerns (below not posted)
Problem 5. Hematologic & Electrolyte Stability
[prognostication and risk stratification in this patient with acute myelomonocytic leukemia (AMMoL)]
Prognostic Implications
Final Prognostic Interpretation
Recommendation for Next Steps
Conclusion
[Filgrastim Use in Breastfeeding Mothers]
To Nurse Practitioner Ni YiJia,
The patient’s daughter is currently breastfeeding and plans to use Filgrastim (G-CSF) to mobilize peripheral blood stem cells for her father’s transplant.
UpToDate states that endogenous G-CSF can be detected in breast milk, and concentrations increase for at least three days post-administration. While recombinant G-CSF is not absorbed orally in infants and adverse effects in breastfeeding infants are rare, some manufacturers advise against breastfeeding during therapy and for two weeks after.
The package insert recommends weighing the benefits of treatment and breastfeeding before making a decision. Pharmacokinetics:
[MedRec]
[mediction]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[S – Subjective]
Chief Complaint:
Patient Narrative:
[O – Objective]
Active Medications:
Recent Medication Change:
Recent Blood Glucose Readings:
Chemotherapy Education & Side Effects:
[A – Assessment]
Diarrhea – Improving
Chemotherapy Side Effects – Monitoring Required
Pancreatic Exocrine Insufficiency – Protase Not on Active List
Blood Glucose Management – Hypoglycemia Risk
[P – Plan]
Medication Adjustments:
Patient Education & Counseling:
Dietary & Glucose Management:
Follow-Up & Coordination:
Next Steps:
[Patient Evaluation]
The patient has pancreatic ductal adenocarcinoma (PDAC), Stage IV (peritoneal carcinomatosis confirmed via biopsy on 2024-12-24). Molecular profiling (NGS 2025-01-24) revealed KRAS G12V mutation, which currently lacks FDA-approved targeted therapies but may be sensitive to experimental pan-KRAS inhibitors or MEK inhibitors in clinical trials.
The patient is undergoing systemic intravenous (IV) chemotherapy with nab-paclitaxel (Abraxane) and intraperitoneal (IP) gemcitabine, an approach aimed at improving local control of peritoneal metastases. Tumor marker trends show CA19-9 decreasing (from 582.05 U/mL on 2025-01-14 to 415.33 U/mL on 2025-02-06), suggesting partial response.
Key clinical considerations:
Problem 1. Pancreatic Cancer with Peritoneal Seeding (Stage IV, KRAS G12V Mutation)
Problem 2. Systemic Effects of Chemotherapy & Cancer (Hematologic, Renal, Nutritional Status) (below not posted)
Problem 3. Pleural Effusion / Disease Progression Monitoring
Final Staging Confirmation
[Assessment of ACTOnco+ Gene Test Results]
The ACTOnco+ test for this patient identified the KRAS G12V mutation with an allele frequency of 4.8%, but no significant copy number variations, gene fusions, or microsatellite instability (MSI) could be determined due to low tumor purity (<30%). Additionally, tumor mutational burden (TMB) could not be assessed.
Summary & Recommendations
Next Steps:
[Recommendation to add Protase (pancrelipase) to active medication list]
Dear Dr./Nurse Practitioner,
I am writing to recommend the addition of Protase (pancrelipase) 280mg, 1 tablet TID to the patient’s active medication list once the diarrhea symptoms have improved.
Rationale for Recommendation:
Proposed Plan:
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
2025-02-04 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2025-01-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-12-17 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-11-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-11-05 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-10-15 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-09-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-08-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-08-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-07-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-06-25 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-06-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-05-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-04-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-04-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 24hr (Avastin + FOLFIRI)
2024-03-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-03-05 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-02-20 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-01-30 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-01-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2023-09-13 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 250mL 46hr (FOLFIRI)
2023-08-23 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 250mL 46hr (FOLFIRI)
2023-08-02 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 250mL 46hr (FOLFIRI)
2023-07-12 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-06-28 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-06-14 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-05-19 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-04-07 (FOLFIRI)
2023-03-22 (FOLFIRI)
2023-03-08 (FOLFIRI)
2023-02-22 (FOLFIRI)
2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2022-02-09 (FOLFOX)
2022-01-26 (FOLFOX)
2022-01-12 (FOLFOX)
2021-12-29 (FOLFOX)
2021-12-15 (FOLFOX)
2021-12-01 (FOLFOX)
2021-11-17 (FOLFOX)
2021-11-03 (FOLFOX)
2021-10-20 (FOLFOX)
2021-10-01 (FOLFOX)
2021-09-09 (FOLFOX)
This is an 83-year-old male with a history of sigmoid colon adenocarcinoma (pT3N1bM0, stage IIIB), multiple lung and liver metastases, chronic viral hepatitis B with delta-agent, hypertensive heart disease, type 2 diabetes mellitus, and benign prostatic hyperplasia. He was admitted on 2025-02-25 due to generalized weakness, malaise, acute back pain, and confusion, leading to an ED visit where hypotension and tachycardia were noted. Given sepsis with lactic acidosis, acute kidney injury (AKI), worsening anemia, and thrombocytopenia, a DNR order was placed, and the patient is under comfort care. Key findings and concerns:
Problem 1. Sepsis with Multiorgan Dysfunction
Problem 2. Acute Kidney Injury and Electrolyte Imbalance
Problem 3. Hematologic Abnormalities (Anemia and Thrombocytopenia)
Problem 4. Cardiac Dysfunction (Atrial Fibrillation with RVR, Myocardial Strain)
No medication reconciliation issues have been identified for this patient.
The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.
[exam finding]
2025-02-25 ECG
2025-02-24 CT - abdomen
2025-02-10 PTCD (percutaneous transhepatic cholangial drainage) revision
2025-02-03 ECG
2025-02-03 CXR
2025-01-24 Percutaneous gall bladder drainage, PTGBD
2025-01-24 SONO - abdomen
2025-01-23 SONO - abdomen
2025-01-22 Sono- and fluoro-guide drainage of ascites
2025-01-21 Esophagogastroduodenoscopy, EGD
2025-01-20 MR cholangiography, MRCP
2025-01-16 SONO - abdomen
2025-01-13 CT - abdomen
2025-01-13 CXR
2024-10-18 CT - chest
2024-10-11 MRI - brain
2024-09-23 Tc-99m MDP bone scan with SPECT
2024-05-28 Tc-99m MDP bone scan with SPECT
2024-05-25 MRI - brain
2024-05-09 CT - chest
2024-02-16 Tc-99m MDP bone scan with SPECT
2024-02-15 MRI - brain
2024-02-07 CT - chest
2023-09-05 MRI - brain
2023-08-23 CT - chest
2023-08-22 Tc-99m MDP bone scan
2023-05-26 MRI - brain
2023-05-04 Tc-99m MDP whole body bone scan
2023-05-03 CT - chest
2023-02-02 Tc-99m MDP whole body bone scan
2023-02-01 CT - chest
2023-01-30 MRI - brain
2022-11-17 Tc-99m MDP whole body bone scan
2022-11-01 CT - chest
2022-09-30 Patho - brain/meninges (tumor)
2022-09-28 MRA - brain
2022-09-28 CT - brain
2022-08-05 Tc-99m MDP whole body bone scan
2022-08-04 CT - chest
2022-05-10 CT - chest
2022-05-06 Tc-99m MDP whole body bone scan
2022-02-10 CT - chest
2022-02-07 Tc-99m MDP whole body bone scan
2021-11-11 Tc-99m MDP whole body bone scan
2021-11-10 CT - chest
2021-08-11 Tc-99m MDP whole body bone scan
2021-08-10 CT, lung/mediastinum/pleura:
2021-08-10 SONO, breast:
2021-08-10 Doppler color flow mapping, 2D transthoracic echocardiography
2021-07 right breast palpable mass with oozing and purulent discharge were noted.
[MedRec]
[counsultation]
[immunochemotherapy]
The patient is a 54-year-old female with HER2-positive metastatic breast cancer (cT4bN1M1, Stage IV), with known metastases to lungs, liver, bones, and brain. She has a history of palliative chemotherapy and targeted therapy, including trastuzumab emtansine (Kadcyla) and trastuzumab deruxtecan (Enhertu). Disease progression has been evident, with worsening hepatic metastases, new-onset obstructive jaundice, and complications including electrolyte imbalances (hypokalemia, hypocalcemia, hypomagnesemia), anemia, and acute kidney injury (AKI). She has undergone percutaneous gallbladder drainage (PTGBD) and percutaneous transhepatic cholangial drainage (PTCD) revisions to manage biliary obstruction. Palliative care involvement was discussed, and DNR preference was documented but lacked family signatures earlier.
Recent imaging reveals progressive liver, lung, and bone metastases, splenomegaly with portal vein encasement, and new ECG findings of sinus tachycardia with old anterolateral/inferior infarcts. Given her hepatic dysfunction, biliary drainage, and ongoing palliative care discussions, careful monitoring and symptom-directed management are essential.
Problem 1. Hepatic Dysfunction with Obstructive Jaundice
Problem 2. Electrolyte Imbalances (Hypokalemia, Hypocalcemia, Hypomagnesemia)
Problem 3. Anemia
Problem 4. Acute Kidney Injury (AKI)
Problem 5. Cardiac Concerns (ECG Abnormalities) - Objective - 2025-02-26 ECG: Sinus tachycardia, old inferior/anterior infarcts. - Prior ECG (2025-02-03): T-wave abnormality, possible anterior ischemia. - Mildly elevated BP and tachycardia seen in recent vitals (2025-02-26).
Problem 6. Palliative Care and Goals of Care Discussion
[reconciliation]
[patient education]
[exam finding]
[surgical operation]
[radiotherapy]
[chemotherapy]
[medication]
[Ref]
Systemic therapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2025-02-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Systemic therapy regimens for pancreatic cancer: Modified FOLFIRINOX - 2025-02-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
[ChatGPT 4o] (not posted)
Based on my review of the NCCN guidelines for breast cancer (2024-10-15) and pancreatic adenocarcinoma (2024-08-02), the following insights are relevant to the patient’s case:
[Patient]
This 58-year-old female with a history of ductal carcinoma in situ (DCIS) of the left breast (2018, s/p BCT+SLND, CR) and recently diagnosed pancreatic head adenocarcinoma (pT2N2, stage III, 2025-01-03, s/p Whipple operation) is now undergoing adjuvant FOLFIRINOX (2025-02-25) per NCCN guidelines (2024-08-02, pancreatic cancer).
She initially presented with epigastric fullness (2024-10), progressive jaundice (2025-01), weight loss (6kg in one month), and abnormal liver function tests. Workup confirmed a pancreatic head tumor (2.7 cm, MRCP 2024-11-29) with lymphovascular invasion and N2 lymph node metastases (12/24 positive, Whipple pathology 2025-01-06).
She is currently on FOLFIRINOX (2025-02-25) with supportive care, including GASMIN (dimethylpolysiloxane), Protase (pancrelipase), and Through (sennoside) for GI support.
[Problems]
Problem 1. Pancreatic Adenocarcinoma (pT2N2, Stage III, s/p Whipple, Adjuvant FOLFIRINOX)
Problem 2. Post-Whipple Nutritional and Digestive Issues
Problem 3. Hematological and Inflammatory Markers
Problem 4: Electrolyte Imbalance (Hypokalemia, Hypocalcemia)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-01-21 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr (Y-sited Covorin) + leucovorin 300mg/m2 400mg NS 250mL 2hr (Y-sited Oxalip) + fluorouracil 300mg/m2 400mg NS 250mL 10min + fluorouracil 2200mg/m2 2700mg NS 500mL 46hr (FOLFOX)
2024-11-26 - oxaliplatin 50mg/m2 70mg D5W 250mL 2hr (Y-sited Covorin) + leucovorin 300mg/m2 430mg NS 250mL 2hr (Y-sited Oxalip) + fluorouracil 300mg/m2 430mg NS 250mL 10min + fluorouracil 2200mg/m2 3000mg NS 500mL 46hr (FOLFOX)
2024-10-08 ~ undergoing - Xeloda (capecitabine 500mg) 1# TID
2024-09-25 ~ 2024-10-02 - Xeloda (capecitabine 500mg) 2# BID
2024-09-09 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2200mg/m2 3300mg NS 500mL 46hr (FOLFOX)
2024-08-23 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2200mg/m2 3300mg NS 500mL 46hr (FOLFOX)
2024-08-06 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2200mg/m2 3300mg NS 500mL 46hr (FOLFOX)
2024-07-17 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX)
2024-06-26 - oxaliplatin 50mg/m2 75mg D5W 250mL 2hr + leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX)
2024-06-03 - ………………………………….. leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX without Oxa)
This 83-year-old female has gastric adenocarcinoma (pT3N3b, cM0, Stage IIIC) post-total gastrectomy (2024-04-17) with D2 lymph node dissection, followed by concurrent chemoradiotherapy (FOLFOX-based chemotherapy and radiotherapy 45 Gy/25 fx completed 2024-11-04). She has multiple comorbidities, including type 2 diabetes mellitus (DM), hypertension (HTN), chronic hepatitis B (anti-HBc reactive), and a history of sepsis.
Her recent clinical course is complicated by pneumonia (Klebsiella pneumoniae, sputum culture 2025-02-01), sepsis (Coagulase-negative Staphylococcus, blood culture 2025-01-30), progressive anemia, severe thrombocytopenia, and electrolyte imbalances (hyponatremia, hyperkalemia, hypocalcemia).
Key recent findings: - Multifocal pneumonia (CXR 2025-02-23) with persistent bilateral lung opacities and consolidations. - Progressive anemia (Hgb 9.9 g/dL, 2025-02-24) and thrombocytopenia (PLT 69 x10³/uL, 2025-02-24). - Severe hyponatremia (Na 122 mmol/L, 2025-02-24). - Metabolic acidosis (HCO3 12.1 mmol/L, BE -10.7 mmol/L, 2025-02-23) and hyperkalemia (K 5.9 mmol/L, 2025-02-23). - Elevated inflammatory markers (CRP 23.8 mg/dL, 2025-02-23; NT-proBNP 9756.9 pg/mL, 2025-02-23). - Underlying chronic liver parenchymal disease (Abdominal SONO 2025-02-05). - History of anterior infarct (ECG 2025-02-03) and frequent premature ventricular complexes (PVCs) (ECG 2024-04-18).
Current treatment: - Active chemotherapy with Xeloda (capecitabine) 500 mg TID (since 2024-10-08) - Antibiotics: Sintrix (ceftriaxone) IV for pneumonia - Supportive care: Baraclude (entecavir), Megest (megestrol), Wecoli (bethanechol), Avelox (moxifloxacin), Rivotril (clonazepam), etc.
The key concerns are ongoing infection, electrolyte disturbances, anemia/thrombocytopenia, and overall disease progression.
Problem 1. Multifocal Pneumonia
Problem 2. Severe Hyponatremia
Problem 3. Progressive Anemia and Thrombocytopenia
Problem 4. Metabolic Acidosis and Hyperkalemia
Final Remarks
[Gastric Adenocarcinoma (pT3N3b, cM0, Stage IIIC) Post-Gastrectomy and Chemoradiotherapy] (not posted)
The primary focus now is assessing for recurrence, optimizing chemotherapy, and improving supportive care to maintain functional status.
[monitoring renal function in FOLFOX treatment]
The patient’s renal function is showing a declining trend. Despite the dose reduction of oxaliplatin in the FOLFOX regimen, if the renal function continues to deteriorate, it may be necessary to reassess the treatment regimen.
2024-07-17 Creatinine 1.30 mg/dL
2024-07-09 Creatinine 0.96 mg/dL
2024-06-26 Creatinine 0.74 mg/dL
2024-07-17 eGFR 41.58 ml/min/1.73m^2
2024-07-09 eGFR 58.99 ml/min/1.73m^2
2024-06-26 eGFR 79.66 ml/min/1.73m^2
[evaluation of iron and vit B12 status following total gastrectomy]
Lab data:
The above lab results suggested that the patient has adequate vitamin B12 and iron levels, which is particularly important following total gastrectomy due to the risk of deficiencies associated with reduced absorption capacities. The elevated vitamin B12 may be due to supplementation, and while not typically harmful, should be monitored to ensure dosages are appropriate. Regular follow-up is crucial to monitor these levels, adjust supplementation as necessary, and check for any signs of micronutrient deficiencies that might not yet be apparent.
[exam findings]
[immunochemotherapy]
[exam finding]
2025-02-23 CXR
2025-02-05 Neck soft tissue
2025-02-05 Nasopharyngoscopy
2025-01-24 SONO - Thyroid
2025-01-19 KUB
2025-01-19 CXR
2024-12-17 CXR
2024-12-13 CT - chest
2024-12-04 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-12-04 2D transthoracic echocardiography
2024-12-03 T-tube cholangiography
2024-12-02 CXR
2024-11-12 T-tube cholangiography
2024-11-11 ECG
2024-10-29 PET
2024-10-09 SONO - abdomen
2024-10-06 Percutaneous Gall Bladder Drainage, PTGBD
2024-10-05 CT - abdomen
2024-10-05 KUB
2024-10-05 CXR
2024-09-23 CXR
2024-09-10 CT - chest
2024-06-26 2D transthoracic echocardiography
2024-06-14 PET
2024-06-03 Patho - lymphnode biopsy
2024-05-27 Nasopharyngoscopy
2024-05-25 CXR
2024-05-17 Patho - colon biopsy
2024-05-17 Pathology Level IV
2024-05-17 EGD
2024-05-06 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-04-30 SONO - abdomen
2024-04-28 KUB
2024-04-15 CT - abdomen
2024-04-12 Colonoscopy
2024-04-08 Patho - stomach biopsy
2024-04-06 EGD
2024-04-02 CT - neck
2024-01-29 PET
2024-01-10 Patho - lymphnode biopsy
2023-12-30 CT - chest
2023-11-08, -11-07 Bladder Sonography
2023-11-07 24hr Holter ECG
2023-11-07 2D transthoracic echocardiography
2023-11-06 MRA - brain
2023-11-06 Neurosonography
2023-11-04 ECG
2023-11-04 CT - brain
2023-09-20 Neurosonography
2023-09-20 Brainstem auditory evoked potential, BAEP
2023-09-13 MRI - larynx
2023-09-13 Sound Field Audiometry
2023-08-30 ENT Hearing Test
2023-06-15 Nasopharyngoscopy
2023-06-05 Nasopharyngoscopy
2023-03-31 CXR
2023-03-30 KUB
2023-03-29 CXR
2023-03-29 PET
2023-03-28 Patho - bone marrow biopsy
2023-03-28 2D transthoracic echocardiography
2023-03-17 Patho - thyroid total/lobe
2023-03-17 Frozen Section - thyroid
2023-03-16 CXR
2023-03-09 CT - chest
2023-02-20 Patho - lymphnode biopsy
2023-02-07 CT - neck
2023-02-01 Nasopharyngoscopy
2022-11-02 Flow Volume Loop
2022-09-23 Hearing Test
2022-08-26 Hearing Test
2022-07-29 Hearing Test
2022-07-05 2D transthoracic echocardiography
2022-07-07 Neurosonology
2022-07-01 ENT Hearing Test
2022-06-21 MRA - brain
2022-06-20 CXR
2022-06-14 CTA - chest
[MedRec]
[consultation] (not completed)
2025-02-05 Ear Nose Throat
2024-12-03 Gastroenterolgy
2024-12-02 Diagnostic Radiology
2024-10-08 Infectious Disease
….-..-..
2023-03-28 General and Digestive Surgery
[surgical operation]
[immunochemotherapy]
Revised Edition of Hematologic Oncology Chemotherapy Drug Prescription (in hospital regimen collection, version 2022-07-04)
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-06-06 https://www.uptodate.com/contents/image?imageKey=ONC%2F63586&topicKey=HEME%2F4729
Cycle length: 21 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance. 2023-06-06 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma
Since the last review on 2025-01-20, the patient has undergone significant developments, including recurrent infection, persistent anemia, lymphoma progression, and initiation of R-GemOx chemotherapy. The three most pressing concerns are:
Problem #1: Residual Infection/Inflammation
Problem #2: Hematologic Status (Anemia and Chemotherapy Risks)
Problem #3: Lymphoma Progression and Treatment Feasibility
Final Considerations
This patient was not suitable for immediate chemotherapy following admission due to clinical signs suggesting a potential infection, which requires stabilization and resolution prior to starting or resuming chemotherapy.
Infection Signs
If Infection is Ruled Out or Recovered - If the suspected infection is treated or deemed non-significant, chemotherapy may proceed. However, certain contraindications or precautions should be addressed:
[Deliberation for Chemotherapy Conduction] (not posted)
Problem #1: Potential Infection
Problem #2: Hematologic Abnormalities
Problem #3: Organ Function and Comorbidities
Problem #4: Lymphoma Progression and Chemotherapy
[Patient Summary]
The patient, an 89-year-old woman, has a complex medical history, including diffuse large B-cell lymphoma (DLBCL), relapsed after treatment with R-miniCHOP, type 2 diabetes mellitus, hypertension, dyslipidemia, chronic viral hepatitis B, and multiple other comorbidities.
She is currently undergoing chemotherapy with R-GemOx as of 2025-01-06. Recent clinical findings indicate progressive interstitial lung disease (ILD) and continued challenges with lymphoma management. Additionally, complications such as gallstones, biliary tract issues, and nutritional challenges are notable.
Key issues revolve around lymphoma progression, treatment complications, and comorbidity management.
[Problem Comments]
Problem #1: Relapsed Diffuse Large B-Cell Lymphoma (DLBCL)
Problem #2: Interstitial Lung Disease (ILD)
Problem #3: Biliary Tract and Gallbladder Issues
Problem #4: Type 2 Diabetes Mellitus
Problem #5: Nutritional and Overall Functional Status
Our endocrinologist wrote a repeat prescription for Zulitor (pitavastatin), Trajenta (linagliptin 5mg) and Dibose (acarbose 100mg) on 2023-08-02 and the drugs are included in the formulary with no reconciliation issue identified.
On 2023-06-08, our neurologist issued a refillable prescription for Plavix (clopidogrel) and diphenidol, and on 2023-06-23, our otolaryngologist prescribed Strocain (oxethazaine polymigel), Acetal (acetaminophen), and cephalexin. Apart from diphenidol, which is no longer necessary due to the resolution of vertigo, all other validly prescribed drugs mentioned have been incorporated into the active medication list without any reconciliation issues.
This patient visited local medical doctor on 2023-05-26, 2023-05-28, 2023-05-29, 2023-05-30, 2023-06-01, 2023-06-04 for her myositis, functional dyspepsia, acute upper respiratory infection, and prescribed acetaminophen, diazepam, loratadine and opium derivatives. for each a short 3-day valid prescription. These symptoms are generally covered in current medical problem list and managed with corresponding same or similar therapeutic class medications. No medication reconciliation issues identified.
Given that this patient has been diagnosed with myositis and dyspepsia that have persisted for months according to the PharmaCloud database, it’s plausible that these could be indicative of statin-induced muscle side effects. Clinical experience suggests that a change in dosing frequency, such as alternate day dosing, may improve statin tolerability in patients experiencing adverse effects such as myalgia. This strategy is particularly beneficial for patients who cannot tolerate daily statin therapy. In addition, alternate-day statin therapy is also considered a cost-effective method to improve drug utilization (Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017;31(4):419-431). Considering the information from these studies and the fact that the laboratory data indicate an improvement in the patient’s hyperlipidemia, it is recommended that the administration of Zulitor be changed from 0.5# QD to 0.5# QOD.
Due to the patient’s advanced age, R-miniCHOP (a dose-reduced version of R-CHOP with reduced amounts of cyclophosphamide and vincristine) was selected as treatment starting on 2023-03-31. One episode of leukopenia was observed (1.56K/uL on 2023-04-12) and was alleviated with two consecutive days of Granocyte (lenograstim) administration. Please monitor for recurrence of leukopenia after this 2nd dose of R-miniCHOP.
Beta-2 microglobulin (b2M) is a major histocompatibility complex (MHC) class I molecule found on the surface of nearly all nucleated cells in the body. Cells with a high turnover rate, such as immune cells and cancer cells, tend to produce and express higher levels of b2M on their surface. In non-Hodgkin’s lymphoma, cancer cells may also have elevated levels of b2M. The elevated levels of b2M observed around the trough of leukopenia may indicate the destruction of cancerous B cells.
Lab data showed that levels above the ULN are associated with type 2 diabetes and hyperlipidemia. Dibose (acarbose), Trajenta (linagliptin) and Zulitor (pitavastatin) are currently appropriately prescribed.
The patient’s cerebral atherosclerosis is treated with Plavix (clopidogrel) and her hepatitis B is treated with Baraclude (entecavir) without an issue.
Hypothyroidism is listed as a diagnosis for the patient, but there is no corresponding medication prescribed currently. The serum free T4 level on 2023-03-17 was 0.57 ng/dL, which is slightly below the normal range. It is recommended to reevaluate the patient’s condition and consider prescribing appropriate medication, such as levothyroxine, if necessary to manage her hypothyroidism.
[drug identification]
The three requested drugs have been identified as follows:
An in-hospital porter will be sent to deliver these medications to the patient’s ward.
[lab data]
2024-04-25 HBsAg Nonreactive
2024-04-25 HBsAg Value 0.49 S/CO
2024-04-25 Anti-HBc Reactive
2024-04-25 Anti-HBc Value 5.73 S/CO
2024-04-25 Anti-HBs 2.11 mIU/mL
2024-04-25 Anti-HCV Nonreactive
2024-04-25 Anti-HCV Value 0.13 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Thrombocytopenia]
Objective
Assessment
Recommendation
Patient Summary
Problem 1. Hyperbilirubinemia and Liver Dysfunction
Problem 2. Thrombocytopenia and Leukopenia (Bone Marrow Suppression)
Problem 3. Hypertension (Suboptimally Controlled)
Problem 4. Hypomagnesemia
[Thrombocytopenia: Trend and Recent Observations]
The patient exhibits a clear and sustained trend of thrombocytopenia (platelet count <150 × 10³/μL), with a recent drop to 46 × 10³/μL on 2024-12-04, reflecting moderate to severe thrombocytopenia.
Platelet Trend Analysis:
| Date | Platelet Count (×10³/μL) | Comments |
|---|---|---|
| 2024-12-04 | 46 | Current; worsening trend. Moderate to severe thrombocytopenia. |
| 2024-11-11 | 50 | Persistent thrombocytopenia; stable but low. |
| 2024-10-14 | 68 | Mild improvement noted but still below normal. |
| 2024-08-29 | 77 | Slightly higher but still thrombocytopenic. |
| 2024-06-25 | 64 | Persistent thrombocytopenia; evidence of fluctuation. |
| 2024-05-31 | 61 | Continuation of low platelet counts. |
| 2024-05-28 | 30 | Severe thrombocytopenia during hospitalization. |
| 2024-05-25 | 45 | Further decline during acute illness. |
| 2024-04-25 | 72 | Baseline thrombocytopenia; evidence of early issues before treatment. |
Causes of Thrombocytopenia in this Patient:
Key Observations in Recent Labs:
Management Recommendations:
[Findings and Management]
Key Findings:
Clinical Concerns
Recommendations
[recommended voriconazole TDM for impaired liver function]
No CRE or VRE culture positives were found, but Aspergillus antigen was confirmed.
For invasive Aspergillosis, voriconazole is usually recommended at a dosage of 6 mg/kg IV/PO Q12H on day 1, followed by 4 mg/kg IV/PO Q12H. However, according to the package insert, in patients with mild to moderate liver impairment (Child-Pugh Class A and B), the standard loading dose should be used, but the maintenance dose should be halved. There are no recommendations for patients with severe liver impairment (Child-Pugh Class C) (Ref: Sanford Guide).
This patient weighs 73 kg. According to the Sanford Guide, the dosing should be 438 mg Q12H on day 1 and then 292 mg Q12H from day 2. Given the patient’s poor liver function, voriconazole therapeutic drug monitoring (TDM) is highly recommended to adjust the maintenance dose.
To order a voriconazole trough level test:
[hyperammonemia management and lactulose dose consideration]
Lactul (lactulose) has effectively controlled the hyperammonemia. If serum ammonia levels remain within the normal range for these days, a reduction in the lactulose dosage or even discontinuation may be considered.
[liver cirrhosis Child-Pugh B classified & Medication Review]
The patient’s discharge diagnoses on 2024-05-17 included cirrhosis of the liver, classified as Child-Pugh Class A.
However, recent lab results indicate a revised classification to Child-Pugh Class B. This is based on updated values: Alb 2.9 g/dL (2 points), PT 13.7 seconds (3 points), and BilT 2.15 mg/dL (3 points). Even encephalopathy and ascites were not counted, these scores total at least 8 points, should be classfied as Class B.
The currently used medications have been reviewed for this Child-Pugh Class B patient, no other medications except Tramacet should be dose adjusted. Use of Tramacet is not recommended as acetaminophen and tramadol undergo extensive hepatic metabolism.
[exam finding]
[MedRec]
[consultation]
2024-12-26 Ear Nose Throat
2024-12-26 Neurology
2024-09-02 Gastroenterolgoy
Sigmoidoscopy for tissue biopsy and stent insertion was indicated if the patient and family could take the risk (organ perforation, etc.)
Explain to the family the indications, procedure, possible complications, stent placement, and related out-of-pocket expenses for a sigmoidoscopy.
If anesthesia is required, please send for anesthesia evaluation.
Colon prepare with EVAC must be done before procedure
Avoid anticoagulants/antiplatelets use if no contraindication
Correct thrombocytopenia and coagulopathy
If the patient and the family all understand the Sigmoidoscopy intervention, would take the risk, and sign the permit for Sigmoidoscopy, the sigmoidoscopy will be arranged on 2024/09/02 afternoon.
2024-08-31 Colorectal Surgery
[immunochemotherapy]
[exam finding]
[consultation]
[MedRec]
[chemotherapy]
This is an 82-year-old female with pancreatic head ductal adenocarcinoma (T4N2M1, stage IV) with liver metastasis, lymph node invasion, duodenal obstruction, and suspected peritoneal carcinomatosis. She has undergone multiple FOLFIRINOX chemotherapy cycles (starting 2024-10-01) and AXIOS LAMS gastrojejunostomy (2025-01-14) for duodenal obstruction. Complicating her condition are:
Problem 1. Pancreatic Head Adenocarcinoma (T4N2M1, Stage IV) with Liver Metastases and Duodenal Obstruction
Problem 2. Progressive Anemia and Hypoalbuminemia (Nutritional Decline and Chronic Inflammation)
Problem 3. Suspected Bone Metastases vs. Benign Compression Fracture
Problem 4. Electrolyte Imbalance (Hyponatremia, Hypocalcemia) (not posted)
[lab data]
2024-11-07 HBV-DNA-PCR Target Not Detected IU/mL
2024-09-13 HBsAg Nonreactive
2024-09-13 HBsAg Value 0.37 S/CO
2024-09-13 Anti-HBc Reactive
2024-09-13 Anti-HBc-Value 5.52 S/CO
2024-09-13 Anti-HCV Nonreactive
2024-09-13 Anti-HCV Value 0.26 S/CO
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[immunochemotheerapy]
The patient is a 59-year-old male with gastric adenocarcinoma (cT3N3bM1, Stage IV, HER2-negative, CPS: 10%) with metastases to the lungs, liver, regional and distant lymph nodes, bones, and adrenal glands. He has been undergoing palliative immunochemotherapy (Nivolumab + FOLFOX) and supportive care with Xgeva (denosumab) for bone metastases since 2024-11-06. His recent condition (2025-02-17) includes:
Given the above, the disease is progressing despite partial responses in some areas (CT 2025-01-08, compared with previous scans). The key concerns include hematologic deterioration, tumor progression, obstructive uropathy, and treatment tolerance.
Problem 1. Progressive Hematologic Deterioration (Anemia & Thrombocytopenia)
Problem 2. Tumor Progression (Increasing CA199 & Bone Metastases)
Problem 3. Obstructive Uropathy of Left Kidney
Problem 4. Nasal Bleeding and Epistaxis
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
The patient, a 49-year-old male, has advanced squamous cell carcinoma of the ventral tongue, floor of the mouth, and lower lip with bilateral lymph node involvement (cT4aN2cM0, stage IVA), undergoing induction chemotherapy with the TPF regimen (Docetaxel + Cisplatin + Fluorouracil). He has multiple comorbidities, including secondary hypertension, diabetes mellitus with neuropathy, hyperlipidemia, and a history of coronary artery disease (CAD). His hospital course has been complicated by methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, a urinary tract infection (UTI) due to Staphylococcus lugdunensis, and drug-induced aplastic anemia.
Problem 1. Acute Pulmonary Symptoms: Cough, Dyspnea, and Lung Infiltration
Problem 2. Chemotherapy-Related Toxicity (Myelosuppression and Gastrointestinal Symptoms)
Problem 3. Cardiovascular Risk and Hypertension
[exam finding]
[MedRec]
[surgical operation]
[Summary]
The patient, a 63-year-old male, has stage IVB non-small cell lung cancer (NSCLC) (cT4N3M1c) with multiple brain metastases, adrenal metastases, and bone metastases. The primary tumor is located in the left lower lung lobe (LLL) with significant systemic involvement. The patient has undergone right frontal craniotomy (2025-01-13) for metastatic brain tumors, palliative whole brain radiotherapy (WBRT) (since 2025-02-06, 17.5 Gy/7 fractions as of 2025-02-14, planned 30 Gy/12 fractions), and palliative radiation therapy for T3 spinal metastases (planned 30 Gy/10 fractions starting 2025-02-17).
Recent imaging (PET 2025-01-17, CT 2025-01-07) confirms progression of intracranial and systemic metastases. The PD-L1 expression is high (TPS 100%, PD-L1 22C3, 28.8, SP142 positive), supporting immunotherapy consideration. EGFR mutation testing is negative (2025-01-17), ruling out targeted therapy for EGFR-driven NSCLC.
The patient exhibits leukocytosis with neutrophilia (WBC 37.13 x10³/uL, neutrophils 98.1% on 2025-02-17), suggesting an active inflammatory/infectious process. Mild normocytic anemia (Hgb 10.3 g/dL, HCT 33.0% on 2025-02-17) and hypoalbuminemia (2.8 g/dL on 2025-02-17) indicate chronic illness-related malnutrition. Electrolyte abnormalities, including hypernatremia (149 mmol/L on 2025-02-17), hypokalemia (3.6 mmol/L on 2025-02-17), and mild hypocalcemia (2.14 mmol/L on 2025-02-17), require correction.
Cardiac evaluation shows cardiomegaly (CXR 2025-02-17) and impaired left ventricular relaxation (Echo 2025-01-09). The enlarged prostate with LUTS, bilateral renal stones, and adrenal metastases (CT 2025-01-09) require urological monitoring.
[Problems]
Problem 1. Stage IVB NSCLC with Multiple Metastases (Brain, Bone, Adrenal)
Problem 2. Severe Leukocytosis with Neutrophilia (Possible Infection vs. Paraneoplastic)
Problem 3. Anemia and Hypoalbuminemia (Malnutrition, Cancer Cachexia)
Problem 4. Electrolyte Imbalances (Hypernatremia, Hypokalemia, Hypocalcemia)
[exam finding]
[MedRec]
[consultation]
[medication]
This is an 88-year-old female with a history of right lower lobe lung adenocarcinoma (cT4N0M1a, stage IVA) (CT 2023-01-17, Pathology 2023-02-03) with EGFR exon 21 (L858R) mutation on Iressa (gefitinib) since 2023-04-14. She also has end-stage renal disease (ESRD) (eGFR 7.62 mL/min/1.73m², Labs 2025-02-16) secondary to chronic kidney disease (CKD) stage 5, type 2 diabetes mellitus (DM), and hypertension, complicated by anemia (Hgb 7.6 g/dL, Labs 2025-02-16) and volume overload with suspected pulmonary edema. She was admitted on 2025-02-16 due to progressive dyspnea over 3 days, leg edema for 1 month, and bilateral lower limb pain for 2 weeks. Key Clinical Issues:
Problem 1. Pulmonary Edema & Pleural Effusions
Problem 2. ESRD & Worsening Azotemia
Problem 3. Severe Anemia
Problem 4. Hypertension & Cardiac Dysfunction
Problem 5. Musculoskeletal Concerns
[exam finding]
[MedRec]
A 91-year-old male with multiple comorbidities, including non-insulin-dependent diabetes mellitus (NIDDM), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and senile dementia, was admitted on 2025-02-15 due to persistent fever for seven days despite antibiotic treatment in Kaohsiung. He has ECOG 4, indicating a poor functional status and dependency on full assistance. Key findings include:
Problem 1. Persistent Fever and Suspected Infection
Problem 2. Glycemic Variability and NIDDM
Problem 3. Liver Dysfunction (Elevated ALT, AST, Hypoalbuminemia)
Problem 4. Electrolyte Imbalance (Hypocalcemia)
[exam finding]
2025-02-11 Bronchodilator Test, BDT
2025-02-07 ECG
2024-12-27 Pathology - prancreas total/subtotal resection
2024-12-20 Body fluid cytology - bile duct brushing
2024-12-20 Endoscopic Ultrasonography, EUS
2024-12-19 Pathology - distal CBD
2024-12-18 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-12-17 T-tube cholangiography
2024-12-16 Endoscopic Ultrasonography, EUS
2024-12-13 Magnetic Resonance CholangioPancreatography, MRCP
2024-12-10 Percutaneous Gall Bladder Drainage, PTGBD
2024-12-09 ECG
2024-12-03 CT - abdomen
2024-12-03 SONO - abdomen
2023-11-03 2D transthoracic echocardiography
[MedRec]
2025-02-11 SOAP Hemato-Oncology Xia HeXiong
2024-12-10 ~ 2025-01-16 POMR General and Gastroenterological Surgery Wu ChaoQun
2024-11-22 SOAP Cardiology Liu ZhiRen
2024-08-30 SOAP Cardiology Liu ZhiRen
2024-06-07 SOAP Cardiology Liu ZhiRen
2024-03-08 SOAP Cardiology Liu ZhiRen
2024-01-12 SOAP Cardiology Liu ZhiRen
2018-04-23 SOAP Cardiology Liu ZhiRen
2018-02-26 SOAP Cardiology Liu ZhiRen
2017-01-05 SOAP Orthopedics Zeng XiaoZu
[consultation]
[surgical operation]
The patient is a 62-year-old woman with tubular adenocarcinoma of the ampulla of Vater (pT3bN1, Stage IIIA) post-Whipple procedure (2024-12-26). She experienced postoperative complications, including bile leakage and intra-abdominal infection (VRE and Candida). Currently, she is planned receiving adjuvant chemotherapy with FOLFIRINOX (this hospitalization). Multiple organ systems require close monitoring, especially considering her past medical history (hypertension, type 2 diabetes mellitus, hyperlipidemia) and ongoing complications (small airway disease and dizziness).
Problem 1. Postoperative Pancreatic Cancer Management and Adjuvant Therapy
Problem 2. Risk of Hepatitis B Virus (HBV) Reactivation
Problem 3. Electrolyte Imbalance (Hypokalemia)
Problem 4. Pulmonary Function – Small Airway Disease and Dizziness
Problem 5. Cardiovascular Risk (Hypertension and Hyperlipidemia)
[exam finding]
[MedRec]
This patient presents with suspected right lung cancer with ipsilateral pleural and lung metastases and right iliac bone metastasis, accompanied by significant respiratory, cardiovascular, metabolic, and musculoskeletal complications. Key findings include:
Problem 1. Suspected Right Lung Cancer with Metastases
Problem 2. Pleural Effusion and Respiratory Insufficiency
Problem 3. Cardiovascular Risks (Atrial Fibrillation, Hypertension, NT-proBNP Elevation)
Problem 4. Bone Metastases & Osteoporotic Fractures
[lab data]
2025-02-10 HLA A-high 11:01
2025-02-10 HLA A-high 33:03
2025-02-10 HLA B-high 40:01
2025-02-10 HLA B-high 58:01
2025-02-10 HLA C-high 03:02
2025-02-10 HLA C-high 07:02
2025-02-10 HLA DQ-high 03:01
2025-02-10 HLA DQ-high 03:02
2025-02-10 HLA DR-high 04:03
2025-02-10 HLA DR-high 11:01
2025-01-08 CMV viral load assay Target Not Detected IU/mL
2025-01-02 CMV IgM Reactive
2025-01-02 CMV IgM Value 2.16 Index
2024-12-31 BM Chromosome Analysis
2024-12-25 FLT3-D835 (BM) Undetectable
2024-12-25 NPM1 (qual)(BM) Presence of mutation
2024-12-23 FLT3/ITD (BM) Presence of mutation
2024-12-23 JAK2 (quan) 0.00 %
2024-12-20 HbA1c 8.5 %
2024-12-18 HBV-DNA-PCR Target Not Detected IU/mL
2024-12-16 Bone marrow cell morphology assessment with differential
cell count 2024-12-16 Age/Sex 73/M
2024-12-16 Clinical information acute leukemia
2024-12-16 Cellularity Hyper.
2024-12-16 M/E ratio 97/3
2024-12-16 Myelo.Blast 76.0 %
2024-12-16 Myelo.Pro. 0 %
2024-12-16 Myelo.Myelo. 5.0 %
2024-12-16 Myelo.Meta. 1.3 %
2024-12-16 Myelo.Band. 7.0 %
2024-12-16 Myelo.Seg. 0.7 %
2024-12-16 Lymphoid series 6.7 %
2024-12-16 Monocyte 0 %
2024-12-16 Plasma cell 1.0
2024-12-16 Megakaryocyte - LPF
2024-12-16 Ery.Pronormo. 0 %
2024-12-16 Ery.Nor.Basophilic 0 %
2024-12-16 Ery.Nor.Poly. 2.3 %
2024-12-16 Ery.Nor.Ortho. 0 %
2024-12-16 MPO negative
2024-12-16 CAE pending
2024-12-16 ANAE pending
2024-12-16 HBsAg Nonreactive
2024-12-16 HBsAg Value 0.44 S/CO
2024-12-16 Anti-HCV Nonreactive
2024-12-16 Anti-HCV Value 0.11 S/CO
2024-12-16 Anti-HBc Reactive
2024-12-16 Anti-HBc Value 5.28 S/CO
[exam finding]
[MedRec]
[chemotherapy]
2025-02-11 - cytarabine 20mg/m2 37mg BID SC 2min D1-7 (venetoclax + low dose cytarabine)
2024-12-24 - daunorubicin 45mg/m2 85mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 192mg 24hr D1-7
Venetoclax - 2025-02-12 - https://www.uptodate.com/contents/venetoclax-drug-information
Treatment Optimization for AML
Current Dose: 100 mg QDCC (started on 2025-02-11).
Recommended NCCN/Uptodate Dosage:
Action Plan:
Risk Consideration:
Current Dose: 20 mg/m² SC BID (started 2025-02-11).
Plan:
Supportive Care Suggestions
Medication Review
[Prognostic and Treatment Implications of Key Genetic and Laboratory Findings]
[Key Summary]
[Problem-Oriented Comments]
Objective:
Assessment:
Recommendations:
[Active Medication Review]
Drug-Drug Interaction:
[Treatment Recommendations for AML]
Given this patient’s age (73 years), comorbidities (CAD, CKD stage III, and DM), and clinical presentation of hyperleukocytosis (WBC = 66.36 x10³/uL, blasts = 22%), an individualized approach is preferred.
Bone marrow biopsy with cytogenetics and molecular testing (e.g., FLT3, IDH1/IDH2 mutations) to guide therapy.
Assess eligibility for targeted therapy if actionable mutations are detected:
Summary
[lab data]
2025-02-11 AFP 80.2 ng/mL
2024-08-26 AFP 11.1 ng/mL
2024-05-20 AFP (NM) 10.166 ng/ml
2024-02-23 AFP (NM) 5.445 ng/ml
2023-12-21 AFP (NM) 3.987 ng/ml
2023-11-24 AFP (NM) 3.797 ng/ml
2023-09-04 AFP (NM) 3.347 ng/ml
2023-03-16 AFP (NM) 3.428 ng/ml
2022-12-08 AFP (NM) 3.545 ng/ml
2022-08-19 AFP (NM) 2.289 ng/ml
2022-06-14 AFP 5.3 ng/mL
2022-05-03 AFP 18.6 ng/mL
2022-05-06 PIVKA-II 377.37 mAU/mL
2022-05-04 ICG (Indocyanine green) 5.5 %
2022-05-04 HBV DNA-PCR (quan) 94.4 IU/mL
2022-05-04 HBeAg Nonreactive
2022-05-04 HBeAg (Value) 0.365 S/CO
2022-05-03 HBsAg Reactive
2022-05-03 HBsAg (Value) 815.43 S/CO
2022-05-03 Anti-HCV Nonreactive
2022-05-03 Anti-HCV Value 0.05 S/CO
[exam finding]
[MedRec]
[consultation]
2025-02-11 Dermatology
2024-11-15 Hemato-Oncology
2024-11-15 Radiation Oncology
2022-05-31 Chest Medicine
2022-05-03 Cardilogy
[surgical operation]
[radiotherapy]
[immunochemotherapy]
This is a 69-year-old man with hepatocellular carcinoma (HCC) with duodenal invasion and bleeding (pT3N0M0, Stage IIIA), previously treated with left hepatic lobectomy (2022-05-12), transarterial chemoembolization (TACE, 4 cycles: 2024-06-03, 2024-07-18, 2024-09-03, 2024-11-08), immunotherapy with atezolizumab (Tecentriq) + bevacizumab (Avastin) (2024-07-18 to 2024-11-07), and radiotherapy (2024-11-25 to 2024-12-25: 4140 cGy/23 fractions to the viable liver tumor and duodenal area for bleeding control).
Despite these interventions, he developed progressive disease with increased AFP (from 11.1 ng/mL on 2024-08-26 to 80.2 ng/mL on 2025-02-11), recurrent gastrointestinal (GI) bleeding, and a large duodenal tumor (EGD 2024-11-14). He was admitted on 2025-02-11 for first-line chemotherapy with FOLFOX. However, FOLFOX is not listed as an NCCN guideline (2025-01-10 version 4.2024) recommended regimen for HCC.
The key issues include:
Problem 1. Progressive Hepatocellular Carcinoma (HCC) with Duodenal Invasion and Bleeding
Problem 2. Hematologic Concerns (Anemia & Thrombocytopenia)
Problem 3. Chronic Hepatitis B with Potential Hepatic Decompensation Risk
Recommendations
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
2025-02-10 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500Ml 46hr (Avastin + FOLFIRI 10% off)
2025-01-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500Ml 46hr (Avastin + FOLFIRI 10% off)
2024-12-13 - (Avastin + FOLFIRI 10% off)
2024-11-29 - (Avastin + FOLFIRI 10% off)
2024-11-11 - (Avastin + FOLFIRI 10% off)
2024-10-14 - (Avastin + FOLFIRI 10% off)
2024-09-18 - (Avastin + FOLFIRI 10% off)
2024-08-31 - (Avastin + FOLFIRI 10% off)
2024-08-16 - (FOLFIRI)
2023-04-26 - (FOLFOX)
2023-04-03 - (FOLFOX)
2023-03-20 - (FOLFOX)
2023-03-02 - (FOLFOX)
2023-02-17 - (FOLFOX)
2023-02-01 - (FOLFOX)
2023-01-06 - (FOLFOX)
2022-12-23 - (FOLFOX)
2022-12-09 - (FOLFOX)
2022-11-25 - (FOLFOX)
2022-11-11 - (FOLFOX)
2022-10-27 - (FOLFOX)
2022-07-18 - (5FU CCRT)
2022-07-11 - (5FU CCRT)
2022-07-04 - (5FU CCRT)
2022-06-27 - (5FU CCRT)
2022-06-20 - (5FU CCRT)
2022-06-15 - (5FU CCRT)
This 65-year-old male with a history of rectal adenocarcinoma (cT3N1M0, initially stage IIIa) post Da Vinci low anterior resection (2022-09-23) and FOLFOX chemotherapy x12 cycles, has lung metastases (cT3N1M1, stage IV) confirmed via biopsy (2024-07-22, VATS wedge resection of right lung lesions). He is currently receiving FOLFIRI + Avastin (bevacizumab) Q2W, with C5D1 administered on 2025-02-10.
Key developments since last review on 2025-01-06:
Tumor Marker Trends:
Chemotherapy Response & Adjustments:
Imaging Follow-Up (CT 2024-12-16):
Hematologic & Biochemical Trends (2025-02-10 vs. 2025-01-14):
No HBV Reactivation (on Baraclude (entecavir), ALT stable).
No Severe Toxicities Observed:
Problem 1. Metastatic Rectal Adenocarcinoma – Lung Metastases
Problem 2. Chemotherapy-Related Toxicities
Problem 3. Liver & Renal Function – Chemotherapy Monitoring
Problem 4. Overall Clinical Status & ECOG Performance
Summary of Recommendations
Overall, the patient is clinically stable, responding well to chemotherapy, and tolerating treatment without major complications. Further monitoring is required to ensure disease control and manage chemotherapy-related side effects effectively.
[Patient Summary]
This patient is a 65-year-old male with a history of rectal adenocarcinoma, initially staged as cT3N1M0 (2022-05-17 colonoscopy and pathology) and ypStage IIA post low anterior resection (LAR) on 2022-09-23 (2022-09-26 pathology). After completing chemoradiotherapy (CCRT) with 5-FU and 12 cycles of FOLFOX, he developed lung metastases confirmed by imaging and biopsy.
Key developments include:
[Problem Comments]
Problem 1. Pulmonary Nodules - Metastatic Colorectal Adenocarcinoma
Problem 2. Tumor Marker Trends - CEA and CA-199
Problem 3. Hepatic Cysts and Liver Status
Problem 4. HBV Reactivation Risk
Problem 5. Ongoing Systemic Therapy - Tolerance and Management
Comprehensive Follow-Up
[IHC and Molecular Profiling for CRC Therapy]
IHC Results and Their Clinical Implications
Targeted Therapy and Immunotherapy Selection
Recommendations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-08-18 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Intaxel 20% off, carboplatin 40% off)
2025-07-14 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Intaxel 20% off, carboplatin 40% off)
2025-06-19 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Intaxel 20% off, carboplatin 40% off)
2025-04-28 - [liposome doxorubicin 30mg/m2 60mg D5W 250mL 90min + carboplatin AUC 5 700mg NS 250mL 90min] IP (for HIPEC)
2025-03-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Intaxel 20% off, carboplatin 40% off)
2025-03-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Intaxel 20% off, carboplatin 40% off)
2025-02-10 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Intaxel 20% off, carboplatin 40% off)
[note]
Venous Thromboembolism (VTE) Anticoagulation: A Practical, Step-by-Step Summary - 2025-09-04 - by ChatGPT5 based on UpToDate
A single, structured guidance from initiation → treatment → extended phase (applies to lower-extremity DVT and acute PE in adults). Always individualize to bleeding risk, comorbidities, kidney/liver function, patient values, availability, and procedures.
One-liner takeaways
Key insight / summary
Problem 1. High-grade serous ovarian carcinoma, FIGO IIIB, on maintenance PARP inhibitor
(below not posted)
Problem 2. Cancer-associated left iliofemoral DVT s/p EKOS, on DOAC; concurrent antiplatelet therapy
Problem 3. Iron-deficiency anemia on background of chemotherapy/PARP; improving but not repleted
Problem 4. Hypertension and chronic ischemic heart disease; polypharmacy and adherence risk
Problem 5. GI mucosal disease with ulcer history under PPI; interaction with clopidogrel
Problem 6. Thyroid function: low TSH with normal Free T4
Problem 7. Renal and hepatic function for drug dosing and safety
Problem 8. Prior urinary tract infection; resolved
Problem 9. Psychosocial context, insomnia, and fall risk while anticoagulated
Problem 10. Electrolytes and minor abnormalities
Notes on evidence/guideline alignment
[Summary]
The patient, a 54-year-old woman with bilateral high-grade serous ovarian carcinoma (pT3bNx, FIGO Stage IIIB), recently initiated first-line chemotherapy with Paclitaxel + Carboplatin on 2025-02-10. She underwent laparoscopic bilateral salpingo-oophorectomy on 2025-01-22, followed by Port-A implantation on 2025-01-24. Imaging (CT 2025-01-24) confirmed peritoneal carcinomatosis with mesenteric and retroperitoneal lymphadenopathy.
Laboratory trends indicate:
She also has chronic viral hepatitis B (HBsAg-negative, Anti-HBc-positive) and is now on Vemlidy (tenofovir alafenamide) to prevent HBV reactivation.
[Problems]
Problem 1. High-Grade Serous Ovarian Carcinoma (FIGO IIIB, pT3bNx)
Problem 2. Chemotherapy-Associated Hematologic and Organ Function Monitoring
Problem 3. Chronic Hepatitis B with Chemotherapy-Induced Reactivation Risk
[exam finding]
[MedRec]
[consultation]
[medication]
The 83-year-old male patient has advanced left lung adenocarcinoma (EGFR mutation: exon 19 deletion, stage IVB) with confirmed metastases to the liver and suspected metastases to the brain and bone. He also has a history of diffuse large B-cell lymphoma (DLBCL) treated with splenectomy and R-COP chemotherapy, along with comorbidities of type 2 diabetes mellitus, essential hypertension, hyperlipidemia, chronic viral hepatitis B, and idiopathic gout. His current admission (2025-02-06) is primarily for pneumonia in the left lung, presenting with dyspnea and thick sputum. Lab results reveal hyperuricemia and mild renal impairment. The patient’s treatment includes oxygen support, antibiotics, and medications to manage hyperuricemia and respiratory symptoms, while Tagrisso (osimertinib) has been temporarily held due to pneumonia.
Problem 1. Pneumonia in the Left Lung
Problem 2. Hyperuricemia
Problem 3. Mild Renal Impairment
Problem 4. Advanced Left Lung Adenocarcinoma with Metastases
[Proposed Improvements for Treatment, Medication Regimens, and Supportive Care Strategies] (just for reference, not posted)
A. Treatment Plan Adjustments
B. Medication Regimen Adjustments
C. Supportive Care Enhancements
D. Summary of Key Recommendations
| Category | Current Approach | Proposed Improvement |
|---|---|---|
| Targeted Therapy | Osimertinib monotherapy | Add carboplatin + pemetrexed combination (if feasible after pneumonia resolution). |
| Second-Line Treatment | No changes yet | If progression, re-biopsy for resistance mutations. If needed, switch to Amivantamab-vmjw + carboplatin + pemetrexed. |
| Pneumonia Management | Levofloxacin 750 mg IV | Consider broader coverage or antifungal if no response. Monitor oxygenation closely. |
| Hyperuricemia | Febuxostat + Sodium Bicarbonate | Increase hydration, titrate sodium bicarbonate, monitor response. |
| Respiratory Support | Inhalers + acetylcysteine | Consider nebulized hypertonic saline or short-course steroids for symptom relief. |
| Nutritional Support | No interventions documented | Consider nutritional counseling and supplements for cachexia prevention. |
| Palliative Care | No engagement documented | Initiate discussions for pain and psychological support. |
[Key Findings and Analysis]
Clinical Context
Imaging and Pathology
Symptoms and Drug History
The patient reports worsening dyspnea, which may be attributed to:
Hyperkalemia (serum K+ 5.3 mmol/L on 2024-11-25), which could worsen dyspnea and requires management.
Hyperglycemia and proteinuria are noted, possibly linked to diabetes or malignancy-related renal dysfunction.
Recommendations for Management
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 76-year-old female with advanced rectal cancer (cT4aN2aM0, stage IIIC) status post transverse loop colostomy (2024-10-23) and Port-A implantation (2024-11-07). She has undergone chemoradiotherapy (CCRT with 5-FU x2 and FOLFOX since 2025-01-10) and pelvic radiotherapy (45 Gy/25 fx completed on 2024-12-20). Comorbidities include rheumatoid arthritis, hypertension, and hepatitis B (carrier, on Baraclude [entecavir]). Her current admission (2025-02-06) is for C2D1 FOLFOX Q2W chemotherapy. She is clinically stable, ECOG PS 1, with mild anemia, normal renal and liver function, and no acute symptoms post-chemotherapy.
Problem 1. Advanced Rectal Cancer (cT4aN2aM0, stage IIIC)
Problem 2. Mild Anemia
Problem 3. Viral Hepatitis B Carrier Status
Problem 4. Hypertension
Problem 5. Rheumatoid Arthritis
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
Granocyte (lenograstim 250ug) CGRAN01 (not completed)
Since last review on 2024-12-17, the patient with advanced pancreatic neck adenocarcinoma (cT4N1M0, stage III) has undergone continued chemotherapy with Gemzar (gemcitabine) and Abraxane (nab-paclitaxel), adjusted for bone marrow suppression. Notable clinical developments include:
Problem 1. Pancreatic Neck Adenocarcinoma, cT4N1M0, Stage III
Problem 2. Anemia
Problem 3. Hypoalbuminemia
Problem 4. Electrolyte Imbalances
[Later-line Treatment Options]
Systemic Therapy Options as Later-line Treatment
Rationale for Avoiding Gemcitabine Rechallenge
Supportive and Adjunctive Therapies
[recurrent neutropenia]
This patient demonstrates recurrent neutropenia associated with chemotherapy for advanced pancreatic adenocarcinoma, complicated by significant disease burden and comorbidities.
Observations
Summary
Recommendations
[Findings and Recommendations]
This patient, a 74-year-old male with a history of adenocarcinoma of the pancreatic neck, cachexia, type 2 diabetes mellitus, chronic hepatitis B, and hypertension. He has undergone liver transplantation and is currently receiving chemotherapy for pancreatic cancer.
Vital Signs and Laboratory Findings
Imaging Findings
Medication Review and Adjustments
Recommendations
[Evaluation of Delayed Gastric Emptying and Management Plan]
Exam results from a gastric emptying study, upper GI series, and EGD (2024-08-20 to 2024-08-22) show clear evidence of delayed gastric emptying (T1/2 = 148.59 minutes), likely due to multiple factors:
Management Considerations:
[Lab Results Overview: electrolyte imbalances and anemia management]
The recent lab results indicate hypokalemia with potassium at 3.1 mmol/L, low albumin at 3.0 g/dL, and low magnesium at 1.8 mg/dL. Hemoglobin (HGB) is also low at 8.5 g/dL, reflecting anemia. The CRP level, at 4.9 mg/dL, suggests an inflammatory response. Potassium and magnesium supplementation have already been initiated, and an LPRBC transfusion was performed to address the anemia. Blood glucose levels are currently well-controlled. Medication reconciliation found no discrepancies.
[Certican (everolimus) blood level monitoring]
Background:
Interpretation:
Recommendation:
[reconcilation]
The patient had an appointment at Tri-Service General Hospital on 2023-09-23 and received prescriptions for Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem), with the latter not currently being utilized. Please verify if the discontinuation of Stilnox is intentional.
As an additional note, the patient received an injection of Zoladex (goserelin acetate) at TSGH on 2023-10-06, with the previous injection administered on 2023-07-28.
This patient had an appointment at the Tri-Service General Hospital on 2023-06-24 where he was prescribed Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem). These medications have been correctly incorporated into the patient’s active medication list. No discrepancies were found during the medication reconciliation process.
This patient had an appointment at the Tri-Service General Hospital on 2023-05-05, during which he was prescribed a single dose of Zoladex (goserelin acetate 10.8mg). As the suggested administration interval for this medication is every 12 weeks, the next scheduled dose should be on 2023-07-28. No issues were discovered during the medication reconciliation process.
The patient seems to be showing signs of anemia with an increasing trend towards macrocytosis. As the bilirubin level is still within the normal range, hemolytic anemia may be less likely. A single intramuscular dose of B-Red (hydroxocobalamin 1mg) is scheduled for 2023-06-02, and folate is already included in the current FOLFIRINOX regimen. At this time, there is no concrete evidence indicating a rapid progression in the severity of anemia, so please continue monitoring.
Zoladex (goserelin acetate) 10.8mg was administered Q3M, with the most recent administration occurring on 2023-05-05, at TSGH for the management of the patient’s prostate cancer. Furthermore, antiglycemic, antihypertensive, and anti-rejection medications prescribed at TSGH are correctly reflected in the current active medication list, presenting no issues with medication reconciliation.
Please be aware, there is a slow yet noticeable upward trend in both AST and ALT lab results. This should be closely monitored for possible potential liver function impairment.
2023-05-10 S-GOT/AST 35 U/L
2023-04-25 S-GOT/AST 42 U/L
2023-04-11 S-GOT/AST 30 U/L
2023-03-28 S-GOT/AST 25 U/L
2023-03-23 S-GOT/AST 30 U/L
2023-03-09 S-GOT/AST 23 U/L
2023-02-22 S-GOT/AST 17 U/L
2023-02-15 S-GOT/AST 16 U/L
2023-01-30 S-GOT/AST 14 U/L
2023-01-13 S-GOT/AST 19 U/L
2023-05-10 S-GPT/ALT 44 U/L
2023-04-25 S-GPT/ALT 55 U/L
2023-04-11 S-GPT/ALT 36 U/L
2023-03-28 S-GPT/ALT 32 U/L
2023-03-23 S-GPT/ALT 35 U/L
2023-03-09 S-GPT/ALT 27 U/L
2023-02-22 S-GPT/ALT 21 U/L
2023-02-15 S-GPT/ALT 22 U/L
2023-01-30 S-GPT/ALT 20 U/L
2023-01-13 S-GPT/ALT 20 U/L
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
2025-02-03 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 250mL 2hr + fluorouracil 300mg/m2 540mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2025-01-10 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 250mL 2hr + fluorouracil 300mg/m2 540mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2024-12-20 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 250mL 2hr + fluorouracil 300mg/m2 540mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2024-11-29 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2024-11-11 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-10-14 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-09-18 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-09-02 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-08-16 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-07-29 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-07-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-06-19 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-05-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-05-17 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-04-25 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-04-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-03-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-03-05 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-02-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-01-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr ……………………………………… + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-01-12 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr ……………………………………… + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2023-12-29 - (Avastin + FOLFIRI) Xia He Xiong
2023-12-11 - (Avastin + FOLFIRI) Xia He Xiong
2023-11-21 - (Avastin + FOLFIRI) Xia He Xiong
2023-11-01 - (Avastin + FOLFIRI) Xia He Xiong
2023-10-13 - (Avastin + FOLFIRI) Xia He Xiong
2023-09-22 - (FOLFIRI) Xia He Xiong
2023-09-01 - (FOLFIRI) Xia He Xiong
2023-08-22 - (FOLFOX) Chen XinHong
2023-08-07 - (FOLFOX) Xiao GuangHong
2023-07-24 - (FOLFOX) Xiao GuangHong
2023-07-10 - (FOLFOX) Xiao GuangHong
2023-06-26 - (FOLFOX) Xiao GuangHong
2023-06-12 - (FOLFOX) Xiao GuangHong
2023-05-29 - (FOLFOX) Xiao GuangHong
This 50-year-old man has advanced sigmoid cancer (pT4bN1bM1a, stage IVA) with metastases to the lungs. His disease was initially treated with surgery (T-loop colostomy, sigmoid colectomy, and small bowel resection in 2023), followed by adjuvant chemotherapy (FOLFOX) and subsequent chemotherapy (FOLFIRI ± Avastin (bevacizumab)). Imaging has demonstrated stable lung nodules without evidence of progression (CT 2025-01-11), suggesting disease control. His performance status remains ECOG 1, and he tolerates chemotherapy without significant adverse events. Supportive care measures, including antiemetics and hydration, have effectively managed side effects. The presence of a growing right renal cyst and a ventral hernia is noted but does not currently compromise his clinical condition.
Treatments and Their Effects
Recommendations for Improvement
[exam findings]
[MedRec]
[consultation]
[surigcal operation]
[immunochemotherapy]
2025-02-04 - Herceptin (trastuzumab) 600mg SC 5min
2025-01-03 - Herceptin (trastuzumab) 600mg SC 5min
2024-12-06 - Herceptin (trastuzumab) 600mg SC 5min
2024-11-12 - Herceptin (trastuzumab) 600mg SC 5min
2024-10-09 - Herceptin (trastuzumab) 600mg SC 5min
2024-09-09 - Herceptin (trastuzumab) 600mg SC 5min
2024-08-15 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-07-20 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-06-21 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-05-25 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-04-26 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-04-02 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-03-11 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2023-06-05 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-05-10 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-04-12 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-03-16 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-02-22 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-01-30 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-12-30 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-12-08 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-11-18 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-10-18 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-09-27 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-09-06 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-08-16 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-06-29 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-06-10 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-05-16 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-04-22 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-04-01 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
2022-03-11 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
2022-02-15 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
2022-01-25 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
[medication]
Lab results on 2024-05-24 were grossly normal and TPR readings during this hospitalization appear to be stable. No medication discrepancies were identified after review of HIS5 and PharmaCloud database.
[monitoring elevated glucose and lipid levels]
The patient exhibited elevated levels of blood lipids and serum glucose. Regular monitoring is advised to determine if any intervention is necessary.
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
This 64-year-old woman, diagnosed with postmenopausal invasive ductal carcinoma of the left breast (ER+, PR-, HER2-, Ki67: 15%, pT2N0M0, stage IIA) post-total mastectomy (2024-08-01), presents with low back pain for one month, progressing over two days, and associated with suspected L4 compression fracture and subacute compression fractures (MRI 2025-01-27). She has received adjuvant chemotherapy with a TC regimen, most recently on 2024-12-20. Imaging (bone scan 2025-01-15) raises concerns about potential bone metastases, degenerative joint disease (DJD), or other etiologies. She is being managed conservatively due to the high infection risk following chemotherapy.
Problem 1. Bone Metastases vs. Degenerative Bone Disease
Problem 2. Breast Cancer Progression
Conclusion:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
2023-12-22 ~ 2024-01-26 - 4000cGy/20 fractions of the right upper gingiva and hard palate tumor bed, hypopharyngeal and esophageal tumor lesions, and 5000cGy/25 fractions of the right upper gingiva and hard palate tumor bed.
2013-12-17 ~ 2014-02-14 - 5000cGy/25 fractions of the oral tongue to bilateral neck area, 6000cGy/30 fractions of the right lateral tongue tumor tumor bed, and 6600cGy/33 fractions of the reduced tumor bed area.
[chemotherapy]
The patient is a 70-year-old individual with recurrent squamous cell carcinoma (SCC) of the right hard palate (pT4aNxaNx, cM0, Stage IVA) post wide excision and prior radiotherapy and chemotherapy. He also has a history of multiple malignancies, including SCC of the tongue and esophagus, and multiple prior treatments, including surgeries, radiotherapy, and chemotherapy. His clinical status on 2025-02-05 remains stable, with ECOG PS 1, clear consciousness, and no significant complaints such as nausea, vomiting, diarrhea, or fatigue. Active chemotherapy (PF4 regimen) with supportive care continues.
Problem 1. Recurrent squamous cell carcinoma of the right hard palate
Problem 2. Organ function and chemotherapy tolerance
Problem 3. Electrolyte imbalance (hypomagnesemia)
Problem 4. Hematologic problem: Mild anemia
Additional Recommendations:
[exam finding]
2025-02-04 KUB
2025-01-23 KUB
2025-01-23 CXR
2025-01-09, -01-02 KUB
2024-12-28 KUB
2024-12-28 CXR
2024-12-20 SONO - abdomen
2024-12-10 Patho - hemorrhoids
2024-11-22 KUB
2024-11-20 Small Intestine Series
2024-11-18 CXR
2024-11-15 CT - abdomen
2024-11-10 KUB
2024-11-10 ECG
2024-10-21 Patho - stomach biopsy
2024-10-21 Esophagogastroduodenoscopy, EGD
2024-09-27 Anoscopy
2024-08-07 MRI - liver, spleen
2024-08-06 PET
2024-07-18 ECG 24hr
2024-07-18 CT - abdomen
2024-05-23 2D transthoracic echocardiography
2024-03-19 CT - abdomen
2024-03-08 Anoscopy
2024-01-08 Patho - gallbladder
2023-12-21 Patho - duodenum biopsy
2023-12-21 Patho - pancreas biopsy
2023-12-20 Endoscopic ultrasound, EUS
2023-12-18 Percutaneous Transhepatic Gallbladder Drainage, PTGBD
2023-12-16 MRI - pancreas
2023-12-12 CT - abdomen
2023-11-20 2D transthoracic echocardiography
2023-10-25 ECG
2023-09-19 Anoscopy
2023-09-06 CXR
2023-09-04 Patho - lung wedge biopsy
2023-09-04 CXR
2023-09-01 SONO - abdomen
2023-08-24 Flow Volume Chart
2023-08-23 CT - chest
2023-07-31 CT - abdomen
2023-05-19 Patho - prostate radical resection
2023-05-03 2D transthoracic echocardiography
2023-04-19 Tc-99m MDP bone scan
2023-04-10 Patho - prostate needle biopsy
2023-04-10 Patho - prostate needle biopsy
2023-03-20 MRI - prostate
2023-02-25 CT - abdomen
2023-01-13 L-spine flex & ext (including sacrum)
2022-11-04 CT - abdomen
2022-07-14 CT - abdomen
2022-03-18 CT - abdomen
2022-01-03 Patho - tendon/tendon sheath
2021-12-10 CT - abdomen
2021-09-01 Patho - interveterbral disc
2021-08-30 Ben densitomerty - spine
2021-08-27 MRI - L-spine
2021-08-13 CT - abdomen
2021-05-16 CT - abdomen
2021-04-23 CT - abdomen
2021-04-23 Bladder Sonography
2021-04-06 Pathology - soft tissue debridement
2021-03-02 Patho - bone marrow biopsy
2021-02-01 CXR
2021-01-15 CT - abdomen
2020-11-18 Ascites Tapping
2020-11-18 SONO - abdomen
2020-10-27 KUB
2020-10-23 Bladder Sonography
2020-10-14 2D transthoracic echocardiography
2020-10-08 Patho - bone marrow biopsy
2020-10-05 SONO - abdomen
2020-09-28 Patho - lymphnode biopsy
2020-09-22 Aspiration cytology - lymph node
2020-09-22 Pathology - lymphnode biopsy
2020-09-22Endoscopic Ultrasonography, EUS
2020-09-21 MRI - upper abdomen
2020-09-21 Sonography - abdomen
2020-07-17 SONO - head and neck
2020-06-29 SONO - head and neck
2020-06-18 Esophagogastroduodenoscopy, EGD
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a 75-year-old male with a complex medical history including pancreatic cancer (cT4N1M0, stage III, portal vein involvement), prostate adenocarcinoma (Gleason score 4+5=9, pT3aN0R1, stage IIIC), peripheral T-cell lymphoma (stage IV with bone marrow involvement), and adenocarcinoma of the right lung (pT1bN0M0, stage IA2). He also has ulcerative colitis, chronic hepatitis B, type 2 diabetes mellitus, hypertensive heart disease, and antiphospholipid syndrome. Recent complaints include general weakness, poor intake due to abdominal pain, intermittent hematochezia, and worsening dyspnea. Significant findings include normocytic anemia (Hgb 8.0 g/dL on 2025-02-04), hypoalbuminemia (2.8 g/dL on 2025-02-04), mild CRP elevation (2.7 mg/dL), stool retention (KUB 2025-02-04), and ongoing ulcerative colitis. Treatment includes parenteral nutrition, antibiotics, and diuretics.
Problem 1. General Weakness, Suspect Related to Poor Intake
Problem 2. Ulcerative Colitis with Abdominal Pain and Hematochezia
Problem 3. Anemia (Normocytic) and Thrombocytopenia
Problem 4. Electrolyte Imbalance
Problem 5. Multiple Cancers with Current Treatment
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Patient Summary
The patient is a 56-year-old woman diagnosed with endometrioid carcinoma (pT1bN0, if cM0, stage IB; 2023 FIGO Stage IICm, p53abn) based on staging surgery performed on 2024-10-28. The pathology showed myometrial invasion >50%, lymphovascular invasion, but no lymph node metastasis (0/35), perineural invasion present, and no omental spread.
She has undergone RT (4500cGy/25 fractions pelvic area + 1200cGy/3 fractions vaginal cuff mucosa) completed on 2025-01-23 and three cycles of chemotherapy with Taxol (paclitaxel) and Carboplatin on 2024-11-26, 2024-12-22, and 2025-01-12, with C4 scheduled on 2025-02-04.
Comorbidities include pre-diabetes mellitus (diet-controlled for 3-4 years) and chronic viral hepatitis B (anti-HBc positive, HBsAg nonreactive). No signs of hepatic decompensation.
Recent lab results on 2025-02-03 show mild anemia (Hgb 9.0 g/dL) and thrombocytopenia (PLT 113 x10^3/uL) with stable renal and liver function. Historical trends suggest chemotherapy-related cytopenia.
Problem 1. Anemia
Problem 2. Thrombocytopenia
Problem 3. Chronic Viral Hepatitis B
Problem 4. Cancer Treatment
Problem 5. Renal and Electrolyte Balance
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - Neoadjuvant Chemotherapy regimen
[Summary]
The patient is a 49-year-old individual with left lip and left buccal squamous cell carcinoma, ypT4aN0M0, stage IVA, complicated by bone metastases (L4 vertebra, left pubic bone) and intracranial invasion. The patient has undergone multiple surgical interventions, including wide excision, free flap reconstruction, and radical neck dissection, and has been receiving systemic chemotherapy and targeted therapy since 2022-10. Currently admitted for chemotherapy with Methotrexate/Leucovorin/Fluorouracil (MTXFL) C1D15 (2025-02-03).
Significant findings include persistent leukocytosis (27.33 x10³/uL) with an elevated CRP (12.1 mg/dL) (CBC 2025-02-03), mild anemia (Hgb 9.6 g/dL) (CBC 2025-02-03), hyponatremia (Na 127 mmol/L) (BMP 2025-02-03), and recent MRI evidence of tumor progression with intracranial invasion (MRI 2025-01-16). Renal function is stable (eGFR 81.58 mL/min/1.73m²) (BMP 2025-02-03), but the patient has chronic kidney disease (CKD stage 3) and hypomagnesemia as comorbidities.
Persistent intermittent fever for the past two weeks, possibly related to infection or tumor-related inflammation, is being managed with empirical cefuroxime therapy (Cefuroxime 1500 mg Q8H) (2025-02-03).
[Problems]
Problem 1. Advanced Squamous Cell Carcinoma with Progression
Problem 2. Leukocytosis and Possible Infection
Problem 3. Electrolyte Imbalance (Hyponatremia, Hypomagnesemia)
There was a gap in follow-up from early 2022-12 to mid 2023-03. The recommended dose of docetaxel and cisplatin in the TPF regimen for head and neck cancer, as listed in the in-hospital collection of chemotherapy regimens as of 2022-02-11, was 40mg/m2 for both drugs. However, the actual administered doses of the two drugs ranged from 50mg to 80mg. For fluorouracil, except for the first 2 doses at 4000mg, all other administrations since 2022-11 were at 3000mg.
If the patient’s dyspnea occurred on 2023-04-06 or 2023-04-07, the TPF dose administered on 2023-04-06 (the 7th dose) was docetaxel 60mg, cisplatin 60mg, and fluorouracil 3000mg all at a reduced amount, which might be less likely to cause dose-dependent adverse reactions. Is it possible that the patient experienced an infusion reaction? If this possibility cannot be ruled out, it may be worth trying a slower infusion rate or adding famotidine 20mg IVD as part of premedication in the next administration.
[exam finding]
[MedRec]
2024-12-10 ~ 2024-12-24 POMR Family Medicine Shen MingChang
2024-11-14 ~ 2024-11-19 POMR Hemato-Oncology Lin YiTing
2022-11-22 ~ 2022-12-03 POMR Hemato-Oncology Zhang ShouYi
The patient presents with multiple concerns including organ dysfunction, hematological abnormalities, electrolyte imbalances, signs of inflammation, and a history of GI and hematologic conditions. Key findings include:
Problem 1. Renal Dysfunction
Problem 2. Inflammatory State
Problem 3. Hematological Abnormalities
Problem 4. Electrolyte Imbalances
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient, a 74-year-old female with a history of squamous cell carcinoma of the right lateral tongue border (cT4aN2cM0, Stage IVA), systemic lupus erythematosus (SLE), hypertension, and type 2 diabetes mellitus, presents with leukocytosis (WBC: 17.68 ×10^3/μL, 2025-02-03) and fatigue. Her ECOG PS is 4, indicating a poor functional status. Historical data reveals prior treatment for tongue cancer (surgery, radiotherapy), lung metastasis, and pneumonia. Current imaging and lab findings suggest ongoing systemic issues that require a multi-system approach to evaluate hematological abnormalities, organ function, and potential underlying infections or malignancy progression.
Problem 1. Leukocytosis
Problem 2. Anemia
Problem 3. ECOG PS 4 with Fatigue
Problem 4. Organ Function (Kidney and Liver)
Problem 5. Infection Risk
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
Key Findings Since 2025-01-08:
Problem 1: Pancreatic ductal adenocarcinoma with liver metastases
Problem 2: Chemotherapy-induced anemia
Problem 3: Pancreatic pseudocyst
[Patient Summary]
The patient is a 66-year-old male diagnosed with pancreatic ductal adenocarcinoma with hepatic metastases (stage IV, cT2N0M1) based on clinical, imaging, and histopathological evidence.
Current treatment includes FOLFIRINOX chemotherapy, reduced to 90% dose due to previous tolerability and patient condition.
Other comorbidities include type 2 diabetes mellitus, coronary artery disease, benign prostatic hyperplasia, and chronic viral hepatitis B.
Monitoring of chemotherapy effects, glucose levels, and vital parameters is ongoing. Recent blood glucose readings (2025-01-07, 2025-01-08) suggest suboptimal glycemic control.
[Problem Comments]
Problem 1: Pancreatic ductal adenocarcinoma with hepatic metastases
Problem 2: Type 2 diabetes mellitus
Problem 3: Coronary artery disease and cardiovascular risk management
Problem 4: Chronic viral hepatitis B
Problem 5: Hyperlipidemia
[exam findings]
, EGD - Findings - Esophagus - Minimal mucosa break<5mm was noted at EC junction. - Stomach - Erythematous change of gastric mucosa was found. - Two ulcer scars were noted at prepyloric antrum, LC and lower body, GC, respectively. - Small grey-white, slightly elevated plaques surrounded by mixed patchy pink and pale areas of mucosa causing an irregular, uneven surface were noted at antrum, low body to angle. - Duodenum - A subepithelial lesion was noted at duodenal SDA, AW side. - Others - There was a hugh ulcer with clean base at right posterior hypopharyngeal wall. - Diagnosis: - Right posterior hypopharyngeal wall ulcer - Reflux esophagitis LA Classification grade A (minimal) - R/O gastric intestinal metaplasia, antrum, low body to angle - Superficial gastritis - Gastric ulcer scars, prepyloric antrum, LC and lower body, GC, respectively - Duodenal SEL, SDA, AW - CLO test: not done
2024-03-21 CTA - brain (head, neck)
2024-03-21 CXR
2023-12-28 ECG
2023-11-16
2023-11-01 MRI - larynx
2023-10-24 Patho - stomach biopsy
2023-10-23 CT - neck
2023-10-23 SONO - abdomen
2023-10-23 EGD
2023-10-20 PET
2023-10-19 Patho - gingival/oral mucosa biopsy
2023-10-19 Nasopharyngoscopy
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[steps for delivering OxyNorm IR capsules via feeding tubes]
When administering OxyNorm (oxycodone) Immediate Release capsules through a nasogastric or gastrostomy tube, begin by flushing the tube with water. Open the capsule and pour the contents directly into the tube. Follow with a 15 mL water flush, then rinse the tube at least two more times with 10 mL of water each. Milk or liquid nutritional supplements can be used as alternatives to water.
[assessing leukopenia risks beyond chemotherapy effects]
The most recent CCRT, which utilized carboplatin, concluded in late Jan / early Feb 2024.
Despite this, the patient is currently experiencing rapidly developing leukopenia, an occurrence unlikely to be induced by the CCRT due to the nearly 2-month gap since its completion.
The administration of piperacillin on 2024-03-18 at KeeLung CGMH (according to PharmaCloud database) is suspected to be a possible cause, as myelosuppression, particularly neutropenia, is a known side effect of this drug.
Should the WBC count continue to decrease, the use of G-CSF may be considered to counteract this effect.
Culture results from both sputum and urine samples collected on 2023-12-29, reported on 2024-01-01, revealed mixed normal flora and less than 1000 CFU/mL, respectively. This, along with the declining CRP level, might suggest a positive response to ongoing cefepime 2000mg Q12H therapy.
Additionally, G-CSF administered since 2023-12-28 has effectively mitigated the leukopenia.
No medication discrepancies were identified during reconciliation.
[MedRec]
[consultation]
[Radiotherapy]
2024-11-26 ~ ….-..-.. - Plan to deliver 45 Gy/ 25 fx to the pancreatic tumor, LAPs, and adjacent lymphatic drainage area.
2024-07-01 ~ 2024-08-23 - completed RT to the seminal vesicles and prostate: 52 Gy/ 26 fx. The prostate: 76 Gy/ 38 fx.
[chemotherapy]
[exam finding]
[Nutritional Strategy for Stage G3 Chronic Kidney Disease: Parenteral Formulation Choices]
Lab Data:
Assessment and Plan:
The above formulations are still appropriate for the patient’s current renal status.
[exam finding]
[MedRec]
The patient is a 63-year-old individual with a history of chronic kidney disease (CKD, stage IV), type 2 diabetes mellitus (T2DM), chronic ischemic heart disease, and mixed hyperlipidemia. The data reflects significant issues with renal function, cardiovascular health, hematological abnormalities (anemia), and potential thyroid dysfunction. The findings also suggest signs of persistent urinary tract infections (UTIs) and possibly autoimmune thyroid disease. Key findings include:
Problem 1. Chronic Kidney Disease (CKD), Stage IV
Problem 2. Anemia
Problem 3. Iron Deficiency
Problem 4. Cardiovascular Abnormalities
Problem 5. Thyroid Disease
Problem 6. Persistent Infections (not posted)
[exam findings]
[MedRec]
[consultation]
2024-12-23 Neurology
2023-11-22 Hemato-Oncology
2023-11-13 Rehabilitation
2023-11-09 Rheumatology and Immunology
2023-11-08 Hemato-Oncology
2023-11-08 Anesthesia
2023-11-05 Neurosurgery
2023-11-05 Neurology
[medication]
ciclosporin 100mg 1# TID PO 2024-02-16 ~ IPD Thymoglobuline 150mg QD IVD 2024-02-24 ~ 2024-02-27 4D
Treatment of aplastic anemia in adults - 2024-03-21 - https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults
The patient, a 75-year-old female with a history of severe aplastic anemia (SAA) and hypertension, presents with pancytopenia, signs of dementia (Clinical Dementia Rating 1), and recurrent infections. Current challenges include hematological abnormalities, organ function impairment, cognitive decline, and electrolyte imbalances.
Problem 1. Severe Aplastic Anemia (SAA)
Problem 2. Cognitive Decline/Dementia
Problem 3. Infection Risk
Problem 4. Cardiovascular and Organ Function
Problem 5. Electrolyte and Metabolic Imbalances
Summary of Priorities
[Diagnosis] (not posted)
The primary diagnosis appears to be severe aplastic anemia (SAA). This diagnosis is strongly supported by the clinical and laboratory findings of pancytopenia, bone marrow hypocellularity, and recurrent infections. Below is a detailed evaluation with differential diagnoses and evidence-based reasoning.
Primary Diagnosis - Severe Aplastic Anemia (SAA)
Differential Diagnoses
Summary
[TDM: proactive reduction of ciclosporin to prevent toxicity]
Since being admitted on 2024-02-16, the patient has been on “Sandimmun Neoral (ciclosporin 100mg) 1# TID”. The trough concentration on 2024-03-05 was 290 ng/mL, and it increased to 368 ng/mL by 2024-03-13. Continuing this trend without reducing the dosage could potentially result in levels exceeding the recommended upper limit of 400 ng/mL next week. Therefore, it’s suggested to decrease the current daily dosage of 300 mg to either 250 mg or 275 mg.
[ciclosporin TDM: acceptable result despite non-ideal blood draw timing (no dosage change)]
The patient is taking Sandimmun Neoral (ciclosporin 100mg) 1# TID.
The TDM for ciclosporin on 2024-03-05 in HIS5 showed that the blood draw time was recorded as 04:21 and the drug administration time was recorded as 09:35, a difference of several hours. Ideally, the trough concentration should be drawn within half an hour before the next administration. The current value is 290 ng/mL, and it should still be within a reasonable range after about 5 hours. Therefore, there is no special dosage adjustment recommended.
Cyclosporine (ciclosporin) trough level target for aplastic anemia:
[blood transfusion safety: recognizing and preventing complications]
Hypocalcemia is observed:
Multiple transfusion complications can arise during or after a blood transfusion:
[lab data]
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
The patient is a 49-year-old woman with a history of rectal adenocarcinoma (cT3N0M0), which underwent neoadjuvant chemoradiotherapy, surgical resection, and adjuvant therapy, achieving complete remission by 2021-09-28. Metastasis to the left lower lobe of the lung (confirmed as metastatic colorectal adenocarcinoma on 2024-04-01) placed her in stage IVA. She has been receiving ongoing chemotherapy with Avastin (bevacizumab) and FOLFIRI since 2024-06-06. Laboratory results from 2025-01-21 indicate relatively stable organ function.
Problem 1. Metastatic Colorectal Adenocarcinoma
Problem 2. Uterine Myoma
Problem 3. Peritoneal Thickening
[lab results clear for Avastin + FOLFIRI treatment]
Lab results from 2024-10-04 indicate normal blood cell counts, electrolytes, and liver and kidney function. These findings suggest that there are no contraindications for the patient to proceed with Avastin + FOLFIRI treatment. No medication issues were identified.
[exam findings]
[MedRec]
[consultation]
[immunotherapy]
2024-05-03 ~ ongoing - Alecensa (alectinib 150mg) 4# BIDCC
2024-07-08 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2024-05-30 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2024-05-03 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2024-04-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2024-03-11 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2024-01-30 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2024-01-05 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-12-06 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-11-03 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-10-11 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-09-15 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-08-25 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-08-04 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-06-13 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-05-12 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-04-14 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-02-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-04-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-03-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-02-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-01-18 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-12-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-11-30 - pembrolizumab 200mg NS 100mL 1hr
2021-11-05 - pembrolizumab 200mg NS 100mL 1hr
2021-10-15 - pembrolizumab 200mg NS 100mL 1hr
2021-09-08 - pembrolizumab 200mg NS 100mL 1hr
2020-10 erlotinib + bevacizumab followed with nivolumab + carboplatin.
[availability of entrectinib and/or alectinib]
According to the latest National Health Insurance (NHI) Drug Reimbursement Guidelines (version dated 2023-05-23), Rozlytrek (entrectinib) is only covered when used alone in adults with ROS-1 positive locally advanced or metastatic NSCLC. Alecensa (alectinib) is covered only for first-line treatment of ALK-positive advanced NSCLC. Both are not covered for papillary renal cell carcinoma.
Both Rozlytrek (entrectinib 200mg/capsule) and Alecensa (alectinib 150mg/capsule) are available in the hospital’s inventory, so no prior authorization is required (no temporary purchase procedure is necessary). The out-of-pocket cost for the former is 1802.5 TWD (NHI price 1530 TWD) and for the latter 487.5 TWD (NHI price 390 TWD).
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
2025-01-20 - pembrolizumab 200mg NS 100mL 30min (Keytruda Q3W)
2024-12-26 - pembrolizumab 200mg NS 100mL 30min (Keytruda Q3W)
2024-11-29 - pembrolizumab 200mg NS 100mL 30min (Keytruda Q3W)
2024-11-19 ~ undergoing - Lenvima (lenvatinib 10mg) 1# QD
2024-11-19 ~ udnergoing - Nolvadex (tamoxifen citrate 10mg) 1# Q12H
2023-11-14 - bevacizumab 15mg/kg 650mg NS 250mL 1.5hr + paclitaxel 150mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 200mg NS 250mL 2hr (Q3W)
2023-09-18 - bevacizumab 15mg/kg 650mg NS 250mL 1.5hr
2023-08-01 - paclitaxel 175mg/m2 200mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr …………………………………… (Q3W)
2023-05-30 - paclitaxel 175mg/m2 235mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
2023-03-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
2023-02-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
This 73-year-old female patient with a history of endometrioid adenocarcinoma (Grade 2, FIGO stage IA), initially treated with surgery and radiotherapy, has developed multiple systemic metastatic lesions, particularly in mesenteric, omental lymph nodes, and liver. Despite undergoing multiple chemotherapy, immunotherapy, and targeted therapy regimens, she now presents with stable disease in the abdomen and lymph nodes.
Problem 1: Systemic Metastatic Endometrioid Carcinoma
Problem 2. Leukopenia
Problem 3. Neuropsychiatric Symptoms (not posted)
This patient refilled Eurodin (estazolam) and Lexapro (escitalopram) on 2023-07-10 issued by our psychosomatic medicine department and these drugs have been included in the active medication list without a reconciliation issue found.
[exam finding]
The patient exhibits several abnormalities across multiple laboratory evaluations between 2025-01-15 and 2025-01-21.
Summary of Differential Diagnoses:
Immediate Recommendations:
[exam finding]
[consultation]
[surgical operation]
[chemotherapy]
2025-01-20 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-12-16 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-11-12 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-10-04 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-08-29 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-07-30 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-06-29 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-05-24 - carboplatin AUC 5 280mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W)
2023-12-26 ~ 2024-05-30 - UFT (tegafur 100mg, uracil 224mg) 2# BID
2023-09-13 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL 2hr (Y-sited carboplatin) (CCRT)
2023-08-31 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-08-24 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-08-17 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-08-10 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-07-27 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-07-19 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-06-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D2-5 (TPF)
2023-05-19 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
2023-04-26 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
2023-03-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 …………………………………………………………………………………. + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
Neoadjuvant Chemotherapy regimen in In-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2022-02-11).
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694
Cycle length: Every 21 days for three cycles.
Regimen
Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694
Cycle length: Every 21 days for four cycles.
Regimen
[Summary]
[Problems]
Problem 1. Advanced Squamous Cell Carcinoma
Problem 2. Renal Impairment
Problem 3. Hematological Abnormalities
Problem 4. Chronic Hepatitis B
[macrocytic anemia]
Macrocytic anemia is present. Common etiologies include vitamin B12 and/or folate deficiency. Supplementation might be considered.
According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital. There are no identified medication reconciliation issues.
The leukocytosis seems to be improving as the patient’s WBC count is nearing ULN. The medications recently used, which include esomeprazole, entecavir, and megestrol, have been reviewed, but none of them are known to significantly affect the WBC count. At the moment, there don’t seem to be any medication-related problems associated with this issue.
Hypomagnesemia has been noted. This might be due to the use of the TPF regimen, which contains cisplatin, and/or the PPI, esomeprazole. During the regimen administration and hospital stay, the patient receives magnesium supplements. Given that hypomagnesemia has been persistent for several months, it may be beneficial to consider magnesium supplementation upon discharge.
[exam finding]
[MedRec]
[surgical operation]
clock position and fiberoptic light pipe was inserted in 2 oclock
position.[chemotherapy]
Systemic therapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) - 2025-01-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
Systemic therapy regimens for gastrointestinal cancer: Modified FOLFOX6 - 2025-01-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F50132
[Patient Summary]
This 73-year-old female patient presents with advanced gastric adenocarcinoma (cT3N3M1, stage IV, HER2-negative, CPS = 8) and a history of left breast cancer (initially pT1cN2aM0, stage IIIA, ER+, PR+, HER2 3+, Ki67 <10%).
She is currently undergoing palliative concurrent chemoradiotherapy (CCRT) for gastric cancer and targeted therapy for breast cancer recurrence. Her condition is complicated by chronic kidney disease (CKD stage 4), type 2 diabetes mellitus, hyperlipidemia, and a thrombotic event in the left post-tibial vein. Key challenges include balancing oncological treatment efficacy with systemic complications such as hematological issues, CKD management, and maintaining overall quality of life.
[Problem Comments]
Problem 1. Gastric Adenocarcinoma with Metastasis
Problem 2. Breast Cancer (HER2-positive)
Problem 3. Chronic Hepatitis B
Problem 4. Chronic Kidney Disease Stage 4
Problem 5. Type 2 Diabetes Mellitus (DM)
Problem 6. Hematological Problems
Problem 7. Electrolyte and Nutritional Imbalances
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-01-20 - oxaliplatin 85mg/m2 50mg D5W 250mL 2hr + leucovorin 400mg/m2 180mg NS 250mL 2hr + flurouracil 2400mg/m2 1000mg D5W 500mL 24hr (FOLFOX. Oxa 30%, FL 25%)
2024-12-30 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 180mg NS 250mL 2hr + flurouracil 2400mg/m2 1000mg D5W 500mL 24hr (FOLFOX. Oxa 50%, FL 25%)
2024-12-02 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr
2024-11-11 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-10-14 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-09-23 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-08-26 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-08-12 - ………………………………….. cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr …………………………………….. (………. Kemoplat ……… CDDP 50% ………..)
2024-07-29 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-07-15 - ………………………………….. cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (………. Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-07-03 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-06-17 - ………………………………….. cisplatin 25mg/m2 37mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (………. Kemoplat + Gemzar. CDDP 80%, Gemzar 50%)
2024-06-11 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 37mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 80%, Gemzar 50%)
2024-05-21 - mitomycin-C 30mg/m2 30mg BI 1hr (MMC)
2024-03-25 ~ 2024-05-13 - TS-1 (tegafur 25mg, gimeracil 7.25mg, oteracil potassium 24.5mg. 25mg) BID PO
2024-05-06 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-04-22 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-04-15 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-04-01 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-03-22 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2023-10-24 - mitomycin-C 30mg/m2 30mg BI 1hr (MMC)
2023-10-16 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-10-09 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-10-02 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-09-25 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-08-18 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-09-11 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-09-01 - mitomycin-C 30mg/m2 30mg BI (bladder irrigation) 1hr (MMC)
The patient is a 59-year-old male with complex medical issues, including intrahepatic cholangiocarcinoma, HBV-related cirrhosis with portal hypertension, diabetes mellitus, and thrombocytopenia. Recent imaging (2024-12-31 SONO) suggests progressive cholangiocarcinoma in the liver (S7 lesion, 4–5 cm mass), cirrhosis-related complications (splenomegaly, ascites), and possible pleural effusion. Hematologic evaluation reveals severe thrombocytopenia (45 x 10³/uL on 2025-01-20), hypoalbuminemia, and elevated tumor markers (CEA, CA19-9). Treatment includes FOLFOX and Pembrolizumab (Keytruda), with some dose adjustments and interruptions. Glycemic control remains suboptimal (HbA1c 7.5%).
Problem 1. Thrombocytopenia
Problem 2. Intrahepatic Cholangiocarcinoma
Problem 3. Liver Cirrhosis with Portal Hypertension
Problem 4. Diabetes Mellitus
Problem 5. Dyslipidemia
Problem 6. Gallbladder Wall Edema
Problem 7. Ascites
[Thrombocytopenia]
Thrombocytopenia in this simulated patient is evident through persistently low platelet counts across multiple dates.
Evidential Review of Thrombocytopenia
Primary Considerations for Thrombocytopenia
Next Steps
[Problem List]
Problem 1. Intrahepatic Cholangiocarcinoma, cT2N0M0, Stage II
Problem 2. Liver Cirrhosis with Portal Hypertension and Splenomegaly
Problem 3. Chronic Hepatitis B Infection
Problem 4. Type 2 Diabetes Mellitus with Suboptimal Control
Problem 5. Recurrent Non-Invasive Papillary Urothelial Carcinoma, Urinary Bladder
Problem 6. Left Hydronephrosis with Double-J Stenting
Problem 7. Anemia
Problem 8. Recent Episodes of Neutropenia
Problem 9. Adverse Effects of Chemotherapy and Immunotherapy
Problem 10. Esophageal Varices
Problem 11. Gastroesophageal Reflux Disease (GERD) and Gastritis
Problem 12. Chronic Cystitis
Problem 13. Elevated Tumor Markers (CEA, CA19-9, AFP)
Problem 14. Chronic Fatigue and Nutritional Deficiencies
Problem 15. Hypermetabolic Lymph Nodes
Problem 16. Biliary Obstruction Risks
[platelet improvement noted despite thrombocytopenia risks - considering platelet transfusion for chronic low platelet counts]
In the 2024-08-27 pharmacist note, the patient’s chronic thrombocytopenia was highlighted, including the incidence of thrombocytopenia with pembrolizumab, cisplatin, and gemcitabine. If the current regimen remains unchanged, platelet transfusion could be considered to reduce the risk of bleeding.
The platelet count recently improved from 35 K/uL to 46 K/uL, showing slight improvement but still remaining below 50 K/uL.
[rising DBI/TBI ratio points to possible biliary obstruction]
Over the past month, the patient’s direct bilirubin levels have increased, along with a rise in the DBI/TBI ratio, suggesting a possible biliary obstruction. If Uliden (ursodeoxycholic acid) is ineffective in resolving the issue, surgical intervention may be eventually necessary to restore normal bile flow.
2024-09-23 Bilirubin direct 0.33 mg/dL
2024-08-26 Bilirubin direct 0.20 mg/dL
2024-07-29 Bilirubin direct 0.13 mg/dL
2024-09-23 DBI/TBI 27.27 %
2024-08-26 DBI/TBI 24.39 %
2024-07-29 DBI/TBI 20.31 %
[Long-Term Decline in Platelet Levels and Thrombocytopenia Risk]
The patient’s platelet (PLT) levels have shown a gradual decline over the past year, with all values falling below the normal range since August 2023. Initially around 50K/uL, PLT levels have frequently dropped below 40K/uL and even 30K/uL since July 2024.
Each medication in the current regimen is associated with a risk of thrombocytopenia, and it is possible that one or more of these drugs are contributing to or exacerbating the condition:
If the clinical risk of bleeding increases, platelet transfusion may be considered.
[lab data]
2024-11-16 EB VCA IgG Positive Ratio
2024-11-16 EB VCA IgG Value 4.3 Ratio
2024-11-14 EB VCA IgM Equivocal Index
2024-11-14 EB VCA IgM Value 0.9 Index
2024-11-14 Anti-HCV (NM) Negative
2024-11-14 Anti-HCV Value (NM) 0.034
2024-11-14 Anti-HBc (NM) Positive
2024-11-14 Anti-HBc Value (NM) 0.071
2024-11-14 Anti-HBs (NM) Positive
2024-11-14 Anti-HBs value (NM) 479.000 mIU/mL
2024-11-14 HBsAg (NM) Negative
2024-11-14 HBsAg Value (NM) 0.453
2024-11-14 VZV IgG Positive mIU/mL
2024-11-14 VZV-G Value 1107 mIU/mL
2024-11-13 CMV IgM Nonreactive
2024-11-13 CMV IgM Value 0.11 Index
2024-11-13 CMV_IgG Reactive
2024-11-13 CMV_IgG Value 222.0 AU/mL
2024-11-13 Anti HTLV I/II Nonreactive
2024-11-13 Anti HTLV I/II Value 0.07 S/CO
2024-11-06 RPR Nonreactive
2024-11-06 HIV Ab-EIA Nonreactive
2024-11-06 Anti-HIV Value 0.05 S/CO
2024-03-06 HLA A-high 02:03
2024-03-06 HLA A-high 33:03
2024-03-06 HLA B-high 51:01
2024-03-06 HLA B-high 58:01
2024-03-06 HLA C-high 03:02
2024-03-06 HLA C-high 14:02
2024-03-06 HLA DR-high 11:06
2024-03-06 HLA DR-high 13:02
2024-03-06 HLA DQ-high 03:01
2024-03-06 HLA DQ-high 06:09
2024-02-22 HBsAg Nonreactive
2024-02-22 HBsAg Value 0.50 S/CO
2024-02-22 Anti-HBc Nonreactive
2024-02-22 Anti-HBc Value 0.35 S/CO
2024-02-22 Anti-HCV Nonreactive
2024-02-22 Anti-HCV Value 0.06 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[PBSCT]
[chemotherapy]
2024-11-25 - methotrexate 10mg/m2 14mg NS 100mL 1hr D1,4,8
2024-11-23 - methotrexate 15mg/m2 22mg NS 100mL 1hr
2024-11-16 - fludarabine 50mg/m2 73mg NS 100mL 1hr D1-5 + busulfan 130mg/m2 190mg NS 500mL 3hr D2-4
2024-10-11 - fludarabine 30mg/m2 43mg NS 100mL 30min D1-5 + cytarabine 2000mg/m2 2890mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 12mg NS 100mL 10min D1-3 (FLAG)
2024-08-15 - fludarabine 30mg/m2 43mg NS 100mL 30min D1-5 + cytarabine 2000mg/m2 2800mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 12mg NS 100mL 10min D1-3 (FLAG)
2024-06-13 - daunorubicin 45mg/m2 62mg NS 100mL 10min D1-2 + cytarabine 100mg/m2 139mg NS 500mL 24hr D1-5
2024-04-16 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 132mg NS 500mL 24hr D1-7
2024-02-23 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 137mg NS 500mL 24hr D1-7
Acute myeloid leukemia: Induction therapy in medically fit adults - 2024-10-15 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
Acute myeloid leukaemia FLAG-Ida (fludarabine cytarabine idarubicin and filgrastim) - 2024-10-15 - https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/347-acute-myeloid-leukaemia-flag-ida-fludarabine
Acute myeloid leukaemia FLAG (fludarabine cytarabine and filgrastim) - 2024-10-15 - https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/346-acute-myeloid-leukaemia-flag-fludarabine-cyta
[CMV Viremia in the Context of MUD Allo-PBSCT]
Lab results
Summary
[Problems]
Problem 1: Persistent CMV Viremia
Problem 2: Risk of End-Organ CMV Disease
Problem 3: Ganciclovir Toxicity Management
Final Recommendations (not posted)
[Ciclosporin Dosage Adjustment]
Based on the lab results and the target therapeutic range of 200–300 ng/mL, the following adjustments are recommended:
Step 1: Current Status
Step 2: Recommended Dosage Adjustment
Step 3: Rationale for Reduction
Step 4: Additional Considerations
[Assessment of allo-PBSCT Timing for the Patient on 2024-11-22] (not posted)
Conclusion
[Developing an appropriate dosing plan for ciclosporin A to achieve a target trough concentration of 200-300 ng/mL in this patient]
| Date | Daily Dose (mg) | Administration Route |
|---|---|---|
| 2024-12-18 | 175 mg | PO |
| 2024-12-19 | 200 mg | PO |
| 2024-12-20 | 175 mg | PO |
| 2024-12-21 | 200 mg | PO |
| 2024-12-22 | 175 mg | PO |
| 2024-12-23 | 200 mg | PO |
| 2024-12-24 | 175 mg | PO |
| 2024-12-25 | 200 mg | PO |
| 2024-12-26 | 175 mg | PO |
| 2024-12-27 | 200 mg | PO |
| 2024-12-28 | 175 mg | PO |
| 2024-12-29 | 200 mg | PO |
| 2024-12-30 | 175 mg | PO |
| 2024-12-31 | 200 mg | PO |
[Increasing Sandimmun Dose to Achieve Therapeutic Range]
Sandimmun 76 mg Q12H IVD was initiated on 2024-11-21. The cyclosporine-A trough level measured on 2024-11-25, was 97 ng/mL, which is below the target range of 100-400 ng/mL.
It is recommended to increase the dose to 80-100 mg Q12H to achieve the desired therapeutic range.
[Analysis and Recommendations for Leukopenia]
Patient History
Key Findings
Assessment of Leukopenia - Primary Causes
Management Recommendations
Prognosis (below not posted)
[early-onset thrombocytopenia linked to MDS before 7+3, following G-CSF protocol in FLAG-ida treatment]
The thrombocytopenia had developed even before the initiation of standard 7+3 and FLAG-ida treatments, with signs appearing as early as late 2023 or early 2024, likely caused by MDS RAEB-II.
For the FLAG-ida regimen, the G represents G-CSF, and it’s recommended to follow the standard protocol: Filgrastim 5 mcg/kg SC once daily from day 0 or 1 to day 5, or continue until neutrophil recovery 1. Alternatively, additional G-CSF may be administered starting 7 days after chemotherapy, until the WBC count exceeds 500/microL 2.
Ref: https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/347-acute-myeloid-leukaemia-flag-ida-fludarabine https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
[Initiation of FLAG-ida Regimen and Neutrophil Count Trends]
The FLAG-ida regimen was initiated on 2024-08-15, and lab results showed an ANC of 966/uL with an upward trend in neutrophil count. The patient’s WBC has been consistently low for months, suggesting that this condition may not be entirely due to chemotherapy.
2024-08-16 Neutrophil 64.0 %
2024-08-10 Neutrophil 19.6 %
2024-07-18 Neutrophil 22.1 %
2024-08-16 WBC 1.51 x10^3/uL
2024-08-10 WBC 1.59 x10^3/uL
2024-07-18 WBC 3.35 x10^3/uL
2024-07-10 WBC 2.54 x10^3/uL
2024-07-08 WBC 1.75 x10^3/uL
2024-07-06 WBC 1.01 x10^3/uL
2024-07-03 WBC 0.89 x10^3/uL
2024-06-30 WBC 0.83 x10^3/uL
2024-06-27 WBC 1.02 x10^3/uL
2024-06-26 WBC 0.83 x10^3/uL
2024-06-24 WBC 1.00 x10^3/uL
2024-06-23 WBC 0.77 x10^3/uL
2024-06-21 WBC 0.67 x10^3/uL
2024-06-17 WBC 0.85 x10^3/uL
2024-06-10 WBC 2.24 x10^3/uL
2024-05-21 WBC 6.29 x10^3/uL
2024-05-13 WBC 2.24 x10^3/uL
2024-05-10 WBC 1.55 x10^3/uL
2024-05-08 WBC 0.93 x10^3/uL
2024-05-06 WBC 0.71 x10^3/uL
2024-05-04 WBC 0.84 x10^3/uL
2024-05-02 WBC 0.78 x10^3/uL
[bedside visit: patient reports improvement in leg swelling and redness]
I visited this patient around 13:40 today, who reported feeling an improvement in the redness and swelling of her legs. She relayed what our dermatologist had said, mentioning that the swollen areas would crust over. However, the patient expressed suspect about the extensive crusting, likening it to her legs undergoing a skin replacement.
The patient had no issues with other medications but remained curious about whether a specific drug could be causing these symptoms.
[ciprofloxacin: short use followed by knee pain & treatment change]
Ciprofloxacin may cause tendinopathy or rupture of tendon; Achilles is most commonly cited, but inflammation/rupture of many other tendons (including hand, rotator cuff, biceps, and thumb) has been reported.
In addition, arthropathy, or joint disease, has been observed in both animal and pediatric human studies following treatment with fluoroquinolone antibiotics, including ciprofloxacin. In an international, multicenter, randomized trial of ~700 pediatric patients (ciprofloxacin versus comparator), more patients in the ciprofloxacin group experienced musculoskeletal events both within 6 weeks and 1 year of follow-up. Arthropathy and arthralgias appear to resolve after discontinuation of treatment with no long-term sequelae. Though the true incidence is unknown, arthropathy and arthralgia are considered to be infrequent, but potentially serious adverse reactions.
Cinolone (ciprofloxacin) was used from 2024-03-07 to 2024-03-09.
On 2024-03-08, the patient reported right knee swelling, pain, and localized heat. After antibiotic therapy with ciprofloxacin. Progression of these symptoms (right knee swelling, pain, and localized heat) was observed.
On 2024-03-09, the cinolone was discontinued. Our dermatologist recommended a regimen consisting of doxycycline, prednisolone, and Topsym Cream (fluocinonide) to address these symptoms.
[bedsite visit]
Upon arrival at 11:30 on 2024-03-11, the patient had just returned to the ward from the dermatology OPD.
I saw the patient had tenderness and swelling near her right knee. There are about five red bumps, each about the size of a coin, near the right knee skin. There is also a slightly red area on her left calf skin, about 7 x 15 cm in size.
I advised her to apply the medications prescribed by our dermatologist and monitor for symptom improvement. If symptoms persist or worsen in these 2 days, further evaluation will be necessary.
[derm suspects erythematous induratum (EI) - workup for underlying cause - evaluation for tuberculosis]
During a visit to dermatology earlier today (2024-03-11), the patient was suspected to have erythematous induratum (EI).
EI is an uncommon form of panniculitis that may occur in association with tuberculosis (most common), other diseases or drugs, or as an idiopathic condition. EI is regarded as an immune-mediated hypersensitivity reaction. EI most frequently occurs in adult females. The most common clinical presentation of EI is single or multiple erythematous nodules on the posterior or lateral lower legs. Thigh and upper extremity involvement occurs occasionally. Truncal, facial, or disseminated EI is rare. Ulceration of nodules is common.
The diagnosis of EI is made based upon the presence of consistent clinical and histologic findings. Skin biopsies demonstrate a predominantly lobular panniculitis with a mixed and granulomatous inflammatory infiltrate with vasculitis. Multiple sections or multiple specimens may be required to identify vasculitis. Given the strong association of EI with tuberculosis, all patients with EI should be evaluated for tuberculosis. (Ref: https://www.uptodate.com/contents/erythema-induratum-nodular-vasculitis)
First-line treatment for nonidiopathic EI is treatment of the underlying associated disease. Nonsteroidal anti-inflammatory drugs, rest, elevation, and compression may aid with symptomatic improvement. When an underlying disease cannot be identified and treated, treatment may be challenging. Data on therapeutic options are limited. It is suggested a trial of oral potassium iodide for these patients (Grade 2C). Other treatments that may be beneficial include systemic glucocorticoids, clofazimine, colchicine, gold salts, and mycophenolate mofetil. Additional immunosuppression may not be optimal for this patients undergoing chemotherapy.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[Renal Function Evaluation - AKI]
Objective
Assessment
Recommendations
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Summary]
[Problems]
Problem 1: Rectal adenocarcinoma with liver metastases (cT3N2bM1a, Stage IVA)
Problem 2: Hematological Monitoring During Chemotherapy
Problem 3: Hepatic Function
Problem 4: Electrolyte and Nutritional Status
Problem 5: Post-surgical Recovery (2024-12-11 Partial Hepatectomy and Colostomy Closure)
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Summary]
[Problems]
Problem 1. Endometrial Serous Carcinoma
Problem 2. Bilateral Lower Limb Pitting Edema
Problem 3. Hematological Concerns
Problem 4. Hypertension
Problem 5. Electrolyte Balance (not posted)
[lab data]
2019-09-24 PD-L1 Cellblock No. S2019-14625A1
2019-09-24 PD-L1 TPS >= 1% and < 50%
2019-09-20 EGFR Cellblock No. S2019-14625A1
2019-09-20 G719X not detected 2019-09-20 Exon19 del not detected
2019-09-20 S768I not detected 2019-09-20 T790M not detected 2019-09-20
Exon20 ins not detected 2019-09-20 L858R Detected 2019-09-20 L861Q not
detected
2019-09-20 ALK IHC Cellblock No. S2019-14625A1
2019-09-20 ALK IHC Negative
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Patient Summary]
This simulated patient is an 81-year-old male with a history of pancreatic ductal adenocarcinoma, left upper lung adenocarcinoma, type 2 diabetes mellitus, chronic kidney disease (CKD) stage 4 (progressing from stage 3), and coronary artery disease (CAD).
The patient has undergone significant surgical procedures, including left upper lobectomy and distal pancreatectomy with splenectomy. Current evaluations highlight worsening renal function, anemia, hyperglycemia, electrolyte imbalances (notably hypokalemia), and evidence of active systemic inflammation (elevated CRP) and tumor marker progression (CEA, CA125, CA199).
[Problem Comments]
Problem 1. Renal Function Worsening (CKD Stage 4)
Problem 2. Anemia
Problem 3. Electrolyte Imbalances (Hypokalemia)
Problem 4. Hyperglycemia
Problem 5. Systemic Inflammation and Tumor Marker Progression
Problem 6. Cardiovascular Risk
[Findings and Comments]
Recommendations
[Doxaben XL tube feeding]
Doxaben XL (doxazosin) is a sustained-release formulation. Switching to Urief (silodosin) is recommended as an alternative to Doxaben.
[Management of a Patient with Advanced Cancer and Chronic Kidney Disease]
Patient’s Chronic Conditions and Oncological History:
Recent Imaging and Pathology Findings:
Laboratory Results and Recent Issues:
Current Medications and Potential Issues:
Blood Glucose and Insulin Management:
Vital Signs Stability:
Renal Function Monitoring and Adjustments:
Oncology Follow-Up:
Anemia Management:
Lab (not posted)
2024-10-29 CA199 1774.70 U/mL
2024-10-15 CA199 987.42 U/mL
2024-09-26 CA199 650.84 U/mL
2024-07-13 CA199 255.38 U/mL
2024-05-21 CA199 (NM) 133.05 U/mL
2024-10-29 CEA 12.19 ng/mL
2024-10-15 CEA 7.56 ng/mL
2024-09-26 CEA 5.10 ng/mL
2024-07-13 CEA 3.82 ng/mL
2024-05-21 CEA (NM) 2.045 ng/mL
[exam finding]
2024-11-08 HBsAg (NM) Negative
2024-11-08 HBsAg Value (NM) 0.347
2024-11-08 Anti-HCV (NM) Negative
2024-11-08 Anti-HCV Value (NM) 0.033
2024-11-08 Anti-HBs (NM) Positive
2024-11-08 Anti-HBs value (NM) 25.600 mIU/mL
2024-11-08 Anti-HBc (NM) Positive
2024-11-08 Anti-HBc Value (NM) 0.008
2024-11-08 AFP (NM) 3.170 ng/ml
2024-11-08 CEA (NM) 2.400 ng/ml
2024-11-08 CA-153 (NM) 12.200 U/ml
2024-11-08 CA-125 (NM) 29.610 U/ml
2024-02-16 Anti-ENA SS-A (Ro) 1140 EliA U/ml
2024-02-14 Anti-ENA SS-B (La) <0.3 EliA U/ml
2021-11-17 Anti-ENA SS-A (Ro) 385 EliA U/ml
2021-11-16 Anti-ENA SS-B (La) <0.3 EliA U/ml
2020-11-12 Anti-HCV Nonreactive
2020-11-12 Anti-HCV Value 0.07 S/CO
2020-11-12 Anti-HBc Reactive
2020-11-12 Anti-HBc Value 4.53 S/CO
2020-11-12 Anti-HBs 0.00 mIU/mL
2020-11-12 HBsAg Nonreactive
2020-11-12 HBsAg Value 0.48 S/CO
[MedRec]
[chemotherapy]
[Hand-foot syndrome]
Hand-foot syndrome (HFS), also known as palmar-plantar erythrodysesthesia, is a well-documented side effect of certain chemotherapeutic agents, particularly liposomal formulations of doxorubicin (2024-12-06). It manifests as redness, swelling, and pain, primarily on the palms and soles. Autoimmune conditions, like rheumatoid arthritis or systemic autoimmune diseases (2024-11-05), can also contribute to similar symptoms, but their presentation is typically different, involving inflammatory arthritis or vasculitis.
Evidence-based evaluation:
Recommendations:
[Potential HBV Reactivation and Need for Prophylaxis]
Background: The patient has serological evidence of past HBV exposure with the following results:
These findings suggest resolved HBV infection (HBsAg-negative, Anti-HBc-positive, and Anti-HBs-positive). However, her clinical history and immunosuppressive treatments place her at risk for HBV reactivation (HBVr).
Risk Factors for HBVr:
Prophylaxis Recommendation: Prophylactic antiviral therapy is indicated. Options include:
Proposed Plan:
[lab data]
2025-01-14 HBsAg Reactive
2025-01-14 HBsAg Value 1247.57 S/CO
2025-01-14 Anti-HBc Reactive
2025-01-14 Anti-HBc Value 6.86 S/CO
2025-01-14 Anti-HCV Nonreactive
2025-01-14 Anti-HCV Value 0.13 S/CO
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Patient Summary]
[Problem Comments]
Problem 1. Recurrent Ovarian Cancer with Splenic Metastasis
Problem 2. HBV-Positive Status
Problem 3. General Metabolic and Hematologic Monitoring
[lab data]
2023-08-23 HBsAg Reactive
2023-08-23 HBsAg Value 4279.15 S/CO
2023-08-23 Anti-HBs 0.02 mIU/mL
2023-08-23 Anti-HBc Reactive
2023-08-23 Anti-HBc Value 7.86 S/CO
2023-08-23 Anti-HCV Nonreactive
2023-08-23 Anti-HCV Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
2025-01-14 - Opdivo (nivolumab) 240mg NS 100mL 1hr
2024-12-16 - Opdivo (nivolumab) 240mg NS 100mL 1hr
2024-07-15 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-06-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-06-03 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46hr (FOLFOX)
2024-05-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46hr (FOLFOX)
2024-04-22 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX)
2024-04-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-01-16 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
2024-01-02 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
2023-12-19 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
2023-12-05 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-11-21 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-11-07 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-10-24 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-10-11 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-09-26 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-09-19 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-09-05 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-08-29 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
Systemic therapy for advanced cholangiocarcinoma - 2024-03-05 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma
[Summary]
This 73-year-old woman with advanced extrahepatic cholangiocarcinoma (post-Whipple operation, 2023-07-26) has metastatic disease involving the lungs and lymph nodes, chronic viral hepatitis B, anemia, and systemic complications. She is currently on nivolumab, an immune checkpoint inhibitor, which introduces additional considerations for her anemia, metastatic disease, and overall care.
[Problems]
Problem 1. Metastatic Extrahepatic Cholangiocarcinoma
Problem 2. Anemia
Problem 3. Chronic Viral Hepatitis B
Problem 4. Reflux Esophagitis and Gastric Issues (hereafter not posted)
Problem 5. Problem: Electrolyte Imbalance (Hyponatremia, Hypokalemia)
The patient, a 73-year-old female with a history of extrahepatic cholangiocarcinoma with pancreatic invasion, is currently undergoing treatment and follow-up for metastatic disease.
Key Summary:
Problem-Oriented Comments:
[lung biopsy planned for extrahepatic bile duct cancer, 2nd line treatment options]
The patient was diagnosed with a malignant neoplasm of the extrahepatic bile duct in the 3rd quarter of 2023 at FuRen University Hospital and subsequently sought chemotherapy treatment at our facility with a regimen of gemcitabine and cisplatin. An attempt to coadminister TS-1 at the beginning of treatment was made but was quickly discontinued due to the patient’s intolerance.
The final dose of the gemcitabine and cisplatin regimen was administered on 2024-01-16, marking nearly six months of treatment, followed by a CT scan on 2024-02-20 that suggested potential disease progression. Currently, the patient is being prepared for a lung biopsy to investigate suspected metastasis.
The patient’s underlying hypertension is now being managed with Concor (bisoprolol) and Exforge (amlodipine, valsartan), aligning with the repeat prescriptions recorded in the PharmaCloud database. The patient’s vital signs and lab results (2024-03-04) were grossly within normal limits, with no discrepancies in medication identified.
Should disease progression be confirmed, several candidate regimens for second-line therapy could be contemplated, encompassing: FOLFOX; liposomal irinotecan; capecitabine combined with oxaliplatin; capecitabine paired with irinotecan; fluoropyrimidine as a standalone treatment; and antiangiogenic therapies, which include bevacizumab, regorafenib, and ramucirumab.
Molecularly targeted therapy represents an alternative approach when next-generation sequencing is employed to identify actionable molecular abnormalities.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Betmiga (mirabegron) - tube feeding]
Betmiga (mirabegron) is a long-acting formulation and is not recommended to be crushed or split for tube feeding. Since the effect of mirabegron 50 mg is approximately equivalent to propiverine 30 mg, switching to Urotrol (propiverine 15 mg) at a dosage of 1 tablet twice daily (BID) is advised for tube feeding.
[Summary]
The patient is a 66-year-old male with advanced intrahepatic cholangiocarcinoma (T4N1M1, Stage IV) undergoing combination chemotherapy (gemcitabine/cisplatin) and immunotherapy (durvalumab). His clinical course is complicated by:
[Problems]
Anemia (HGB 9.0 g/dL on 2024-12-30)
Persistent Inflammatory State
Track inflammatory markers (e.g., CRP, procalcitonin) and WBC count. - Repeat blood cultures to confirm clearance of bacteremia. - Chest imaging (e.g., CT) to assess for structural lung pathology or abscess.
Electrolyte and Nutritional Imbalances
[anemia]
The patient presents with anemia, evident from consistent findings of low hemoglobin (HGB) levels across multiple dates.
Classification of Anemia
Temporal Evidence
Contributing Factors and Etiologies
Suggested Next Steps
[exam findings] (not completed)
[MedRec] (not completed)
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
G-CSF
There were no medication reconciliation issues when reviewing PharmaCloud and HIS5 records.
[Leukemia has been managed more effectively]
Leukopenia has become less severe and less frequent following the intermittent administration of prophylactic/therapeutic Granocyte (lenograstim) in accordance with chemotherapy cycles. This approach has improved the management of this side effect.
[reconciliation]
Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.
[leukopenia]
At this time, the patient is not experiencing severe leukopenia. Any leukopenia events that have occurred since the start of the [bevacizumab paclitaxel cisplatin] regimen on 2023-05-26 have been treated with G-CSF administrations without reducing the dose of paclitaxel or cisplatin.
Based on the PharmaCloud database, this patient has exclusively attended our hospital for outpatient and inpatient services across the departments of urology, obstetrics and gynecology, radiation-oncology, and hemato-oncology in the past three months. No issues were found during medication reconciliation.
[reconciliation]
[more intensive hydration]
[leukopenia]
This patient last received paclitaxel and cisplatin on 2023-05-15 and a WBC nadir of 1.16K/uL was noted on 2023-05-25. Paclitaxel carries a Boxed Warning regarding bone marrow suppression and recommends frequent peripheral blood cell counts for all patients receiving the drug. Granocyte (lenograstim 250ug) was administered for three consecutive days starting on 2023-05-25.
According to the reimbursement guidelines of the Taiwan National Health Insurance, the use of G-CSF is allowed for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an absolute neutrophil count (ANC) of less than 500/uL after chemotherapy. This patient meets the specified criteria (neutrophil 14.7%), so G-CSF can be prescribed to manage leukopenia following this round of chemotherapy.
[exam findings]
[MedRec]
[immunochemotherapy]
2025-01-10 - pembrolizumab 200mg NS 100mL 30min (Keytruda self-paid)
2024-12-11 - pembrolizumab 200mg NS 100mL 30min (Keytruda self-paid)
2024-11-19 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-10-24 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-09-17 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-08-23 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-08-01 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-07-09 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-06-12 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-05-20 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 340mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
[Patient Summary]
The patient is a 47-year-old postmenopausal woman with a history of endometrial adenocarcinoma with lymph node metastases (pT3aN1M0, FIGO pStage IIIC1) diagnosed in 2014 and treated with surgery and chemotherapy.
She developed recurrent bilateral lung metastases in 2017 and is currently receiving immunotherapy with Keytruda (pembrolizumab) along with a regimen of paclitaxel and carboplatin, followed by maintenance therapy with Keytruda (pembrolizumab). The disease appears stable on imaging (2024-11-20 CT, 2024-05-21 bone scan) without significant new progression.
Management also involves chronic viral hepatitis B and symptom control for treatment-related side effects.
[Problem Comments]
Problem 1: Lung Metastases
Problem 2: Chronic Viral Hepatitis B
Problem 3: Fatty Liver
Problem 4: Potential Bone Metastases
Problem 5: Anemia
Hypokalemia was noted on 2024-07-08. Oral potassium supplementation (Const-K) is currently used, no medication problems found.
[exam finding]
[MedRec]
[consultation]
[Medication]
[Fosamax Plus - tube feeding]
The FOSAMAX PLUS (alendronate 70mg, colecalciferol 140 ug 5600 IU) package insert states: “Similar to other formulations containing bisphosphonates, FOSAMAX PLUS may cause localized irritation to the upper gastrointestinal mucosa. The risk of severe esophageal adverse reactions is heightened if patients lie down after taking FOSAMAX PLUS, fail to accompany the medication with a full glass of plain water, or continue its use despite experiencing esophageal irritation.”
Administration of the medication via tube feeding, bypassing the esophagus, should theoretically not result in esophageal mucosal irritation.
[Problem Comments]
Problem 1: Sepsis with Multi-Organ Dysfunction
Problem 2: Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD)
Problem 3: Liver Dysfunction and Hepatic Encephalopathy
Problem 4: Pleural Effusions and Respiratory Dysfunction
Summary of Key Actions (not posted)
[Problem Comments]
Problem 1: Infection and Suspected Sepsis
Problem 2: Hyperglycemia and Suboptimal Glycemic Control
Problem 3: Hypercoagulable State
Problem 4: Electrolyte Imbalance (Hyperkalemia)
[Hypercoagulability and Risk of Thrombosis] (not posted)
Assess Coagulation Status
Manage Hypercoagulability and Risk of Thrombosis
Address the Systemic Infection
Glycemic Control
Address Electrolyte Imbalances
Monitor and Manage Oncological Issues
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-01-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-12-11 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-11-18 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-09-09 - (debulking surgery)
2024-07-31 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-07-06 - paclitaxel 175mg/m2 265mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-06-17 - paclitaxel 175mg/m2 265mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
[successful reduction of ca125 with paclitaxel and carboplatin]
The tumor marker CA125 readings have continued to decrease after initiating the paclitaxel and carboplatin regimen on 2024-06-17. Lab data on 2024-07-30 were generally acceptable. No medication discrepancies were identified.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Patient Summary]
This is a 77-year-old patient diagnosed with ductal adenocarcinoma of the pancreatic tail, pT2N0M1, Stage IV, with progression of metastatic pleural disease. The primary tumor has remained stable, but pleural effusion and pleural seeding have worsened. The patient is undergoing systemic chemotherapy, with gemcitabine, nab-paclitaxel, and cisplatin added later, potentially reflecting attempts to address platinum-sensitive disease (e.g., suspected BRCA1/2 or PALB2 mutation sensitivity).
[Problem Comments]
Problem 1: Metastatic Pleural Effusion with Pleural Seeding
Problem 2: Primary Pancreatic Tail Tumor
Problem 3: Systemic Disease Burden and Treatment Tolerance
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Patient Summary]
The patient is a 40-year-old male diagnosed with non-small cell lung carcinoma (NSCLC), favoring adenocarcinoma, with multiple bone metastases, including the cervical spine, thoracic spine, and left femur, among others. The disease is staged as cT4N3M1c, Stage IV, with extensive bony destruction and systemic metastases evidenced by imaging and laboratory findings (2024-12-07 CT, 2024-12-13 PET, 2024-12-12 bone scan).
He is undergoing systemic therapy with Cisplatin/Paclitaxel and radiation therapy for both the primary tumor and metastatic lesions (2024-12-18 chemotherapy initiation, 2024-12-13 XRT initiation). The patient also experiences paraneoplastic symptoms, including hypercalcemia, which was initially treated successfully (2024-12-05 lab corrected calcium 3.26 mmol/L).
Despite treatment, the disease continues to progress with lower limb paralysis secondary to spinal cord compression by metastatic lesions (2024-12-23 MRI findings). He is currently on a multimodal palliative treatment plan that includes pain control, radiotherapy, and systemic chemotherapy.
[Problem Comments]
Problem 1: Non-Small Cell Lung Carcinoma (NSCLC) with Bone Metastases
Problem 2: Spinal Cord Compression
Problem 3: Hypercalcemia
Problem 4: Pain Management
[exam finding]
[consultation]
[chemotherapy]
[Patient Summary]
This 60-year-old male patient presents with advanced transverse colon adenocarcinoma (diagnosed via biopsy on 2024-12-24), complicated by peritoneal carcinomatosis, liver and lung metastases, and multiple lymph node metastases (imaging evidence: MRI 2024-12-25 and CT 2024-12-17). The patient also has a history of chronic hepatitis B (diagnosed 30 years ago). Current concerns include refractory hypotonic hyponatremia with hypervolemia, anemia, and significant weight loss (10 kg over 3 months). Initial chemotherapy with modified FOLFIRI + Avastin (irinotecan 20% off) started on 2025-01-05.
[Problem Comments]
Problem #1: Advanced Transverse Colon Adenocarcinoma with Metastases
Problem #2: Refractory Hypotonic Hyponatremia with Hypervolemia
Problem #3: Anemia
Problem #4: Chronic Hepatitis B
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Patient Summary]
This is a 68-year-old male patient with a history of lung squamous cell carcinoma (pT2aN1M0, stage IIB), chronic obstructive pulmonary disease (COPD), chronic systolic heart failure, ischemic heart disease, and coronary artery disease (CAD) status post percutaneous coronary intervention (PCI) with a drug-eluting stent in the right coronary artery and a drug-coated balloon in the left anterior descending artery (2024-05-16). Following a right lower lobe lobectomy and lymph node dissection on 2024-11-20, the patient is planned for adjuvant chemotherapy (weekly docetaxel and cisplatin) with consideration for concurrent chemoradiotherapy (CCRT) due to suspected close surgical margins (2025-01-03). Pre-chemotherapy considerations include renal function monitoring (creatinine clearance and 24-hour CCr on 2025-01-04) and management of underlying conditions.
[Problem Comments]
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Patient Summary]
The patient, a 58-year-old woman, has been diagnosed with invasive lobular carcinoma (2024-07-31 pathology) of the right breast (ER+, PR+, HER2-, Ki-67 5%) with a history of partial mastectomy and axillary lymph node dissection. Post-surgery, the patient underwent adjuvant chemotherapy with Doxorubicin + Cyclophosphamide (2024-08-22 to 2024-11-04) and transitioned to Docetaxel-based chemotherapy (2024-11-25 to 2025-01-06). Complications include neutropenia (grade II, 2024-12-19) and metabolic imbalances (hypomagnesemia, hypocalcemia, 2024-12-19). The patient also has a history of chronic hepatitis B managed with Vemlidy (tenofovir alafenamide).
Laboratory findings reveal hyperglycemia with blood glucose ranging from 214 to 287 mg/dL on 2025-01-05 to 2025-01-06, which could indicate steroid-induced diabetes or poor glucose control. Vital signs are stable with no acute abnormalities in blood pressure or SpO2 (2025-01-05 to 2025-01-06).
[Problem Comments]
Problem 1. Breast Cancer Management
Problem 2. Metabolic Imbalances (Hyperglycemia, Hypomagnesemia, Hypocalcemia)
Problem 3. Chronic Hepatitis B
Problem 4. Neutropenia (Grade II)
[Treatment Assessment]
Based on the patient data from HIS5 and the referenced NCCN guidelines (2024-10-15)
Start an aromatase inhibitor (AI) (e.g., Letrozole, Anastrozole, or Exemestane) following the completion of chemotherapy (Docetaxel, 2025-01-06).
Consider adjuvant bisphosphonate therapy (e.g., zoledronic acid) to counteract AI-induced bone loss, as she is at risk of osteoporosis.
Proposed Plan
[exam finding]
2024-12-07 11:25 ECG
2024-12-05 Patho - gallbladder (benign lesion)
2024-12-05 Patho - liver partial resection
2024-11-21 Flow Volume Chart
2024-11-21 2D transthoracic echocardiography
2024-11-19 Percutaneous Transhepatic GallBladder Drainage, PTGBD
2024-11-18 Patho - pancreas biopsy
2024-11-18 Endoscopic ultrasound, EUS
2024-11-18 SONO - abdomen
2024-11-14 MRI
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Patient Summary]
This 73-year-old male patient with pancreatic head adenocarcinoma (moderately differentiated), complicated by liver metastases (evidenced by imaging and pathology on 2024-12-05), has undergone significant surgical and medical management. He has a history of obstructive jaundice (2024-11-14), Type 2 diabetes mellitus (DM), hypertension, and asthma. Recent treatments include a Roux-en-Y gastrojejunostomy, hepaticojejunostomy, open cholecystectomy, and liver partial resection (2024-12-05). Currently, he is undergoing chemotherapy with Gemzar (gemcitabine) and Abraxane (nab-paclitaxel) initiated on 2025-01-03.
He presents with anemia, persistent elevated liver enzymes, fluctuating bilirubin levels, controlled glycemic levels, and an ECOG performance status of 1 post-surgery.
[Problem Comments]
Problem 1. Pancreatic Head Adenocarcinoma with Liver Metastasis (Stage IV)
Problem 2. Anemia
Problem 3. Diabetes Mellitus (DM)
Problem 4. Nutritional Deficiencies
Probelm 5. Biliary and Liver Function
Problem 6. Pulmonary Function
Problem 7. Pain Management
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
2023-10-31 ~ 2023-11-13 - completed RT to spine T10-L1: 30 Gy/ 10 fx.
2023-03-16 ~ 2023-04-28 - completed RT to the rectal tumor and regional LNs: 45 Gy/ 25 fx. The rectal tumor (with the invaded uterus) and LAPs: 54 Gy/ 30 fx.
[chemotherapy]
2024-12-18 - cetuximab 500mg/m2 400mg 2hr + oxaliplatin 65mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (infusor) (Erbitux + FOLFOX. Erbitux only 4 vials left)
2024-12-03 - cetuximab 500mg/m2 600mg 2hr + oxaliplatin 65mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (infusor) (Erbitux + FOLFOX)
2024-11-07 - leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 425mg/m2 630mg NS 250mL 10min (5-FU for CCRT)
2024-10-04 - cetuximab 500mg/m2 700mg 2hr + oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 440mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFOX)
2024-09-09 - cetuximab 500mg/m2 700mg 2hr + oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 440mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFOX)
2024-08-24 - cetuximab 500mg/m2 700mg 2hr + irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFIRI)
2024-07-31 - cetuximab 500mg/m2 700mg 2hr + irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFIRI)
2024-07-08 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr + irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-06-17 - ……………………………………. leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
2024-05-28 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-05-09 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-04-17 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-03-22 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-01-18 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-12-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-12-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-11-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-09-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-09-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
2023-08-01 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
2023-07-12 - ………………………………….. irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
2023-06-26 - ………………………………….. oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
2023-05-29 - bevacizumab 5mg/kg 300mg NS 200mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
2023-04-28 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
2023-04-11 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
2023-03-23 - ………………………………….. oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFOX, Q2W)
[Key Summary]
The patient is a case of a critically ill individual with advanced metastatic rectal cancer (cT4aN2bM1a, stage IVA), significant liver and lung metastases, portal hypertension, ascites, thrombosis of the left portal vein, and secondary complications including renal dysfunction, infection, anemia, and malnutrition.
Current findings suggest systemic inflammation/infection (elevated procalcitonin: 8.06 ng/mL on 2025-01-01), acute kidney injury (creatinine: 2.27 mg/dL on 2025-01-01, eGFR: 23.11 mL/min/1.73 m²), progressive anemia, and coagulopathy. The patient is receiving critical support, including intravenous (IV) albumin, vasopressors, and antibiotics.
[Problem Comments]
Problem 1. Sepsis/Systemic Inflammation
Problem 2. Acute Kidney Injury (AKI)
Problem 3. Anemia and Coagulopathy
Problem 4. Hyperbilirubinemia and Malnutrition
[monitoring upward trend in CEA and CA199, addressing liver cirrhosis and metastasis, potential sodium supplementation for hyponatremia]
Lab results on 2024-05-27 showed hyponatremia (130 mmol/L), hypomagnesemia (1.7 mg/dL), hyperalbuminemia (3.3 g/dL), and hyperbilirubinemia (total 1.22 mg/dL, direct 0.40 mg/dL). The latter two are likely related to liver cirrhosis and metastases. Currently, MgSO4 and BaoGan are in use. The addition of sodium supplementation might be further considered.
The CT imaging conducted on 2024-03-25 showed that the rectal cancer with liver metastases remained stationary. However, the updated markers CEA and CA199 seem to be trending upward and should be closely monitored.
2024-05-15 CEA 52.67 ng/mL
2024-04-25 CEA 41.73 ng/mL
2024-04-01 CEA 26.22 ng/mL
2024-03-12 CEA (NM) 18.827 ng/mL
2024-02-02 CEA (NM) 9.794 ng/mL
2024-01-18 CEA 15.20 ng/mL
2024-01-16 CEA (NM) 4.550 ng/mL
2024-05-15 CA199 46.60 U/mL
2024-04-25 CA199 36.37 U/mL
2024-04-01 CA199 27.00 U/mL
2024-03-12 CA199 (NM) 52.022 U/mL
2024-02-02 CA199 (NM) 37.571 U/mL
2024-01-18 CA199 27.25 U/mL
2024-01-16 CA199 (NM) 34.438 U/mL
[thrombocytopenia]
Thrombocytopenia was first observed in April 2023 and has not yet returned to the lower limit of normal range (150K/uL). Since December, platelet counts have been consistently below 50K/uL. Bevacizumab was started in August 2023.
Both bevacizumab and fluorouracil are known to cause thrombocytopenia, with bevacizumab showing a higher incidence rate of up to 58% (grades 3/4: 20% to 40%).
According to UpToDate recommendations, in cases of hemorrhage caused by bevacizumab, such as hemoptysis (recent history of >= 2.5 mL), bevacizumab should be withheld. For Grade 3 or 4 hemorrhage, bevacizumab should be discontinued. As there has been no recent documentation of hemorrhage found in the medical records, it may not be necessary to temporarily stop the use of bevacizumab at this time.
Blood transfusion has been scheduled according to the progress note.
The patient has only visit our hospital in the last 3 months according to the PharmaCloud database, our gastroenterologist prescribed Baraclude (entecavir) for she is a carrier of viral hepatitis B. Baraclude is in the active medication list, no reconciliation issues found.
On 2023-06-18, the patient’s fecal occult blood test was 2+, indicating a possible GI bleeding. On this date, the patient has been prescribed lansoprazole and tranexamic acid. The prescription for lansoprazole is set to expire on 2023-06-21. It would be beneficial to evaluate whether signs of bleeding persist to decide whether to continue the PPI.
[exam finding]
[MedRec]
2024-12-31 ~ 2025-01-01 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-11-01 ~ 2024-11-02 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-09-16 Radiation Oncology Chang YouKang
2024-09-13 ~ 2024-09-14 POMR General and Gastroenterological Surgery Zhang JianHui
2024-09-10 Radiation Oncology Chang YouKang
2024-09-05 SOAP Gastroenterology Li ZhongXian
2024-08-26 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-08-06 SOAP Radiation Oncology Chang YouKang
2024-08-05 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-07-15 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-24 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-13 SOAP Gastroenterology Li ZhongXian
2024-06-12 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-03 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-05-10 ~ 2024-05-11 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-04-18 ~ 2024-04-19 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-03-27 ~ 2024-03-28 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-02-21, -02-07 SOAP General and Gastroenterological Surgery Zhang YaoRen
2023-11-22, -08-30, -06-07 SOAP General and Gastroenterological Surgery Zhang YaoRen
2023-03-15, 2022-12-21, -09-28, -06-30 SOAP General and Gastroenterological Surgery Zhang YaoRen, Zhang JianHui
2022-06-06 SOAP General and Gastroenterological Surgery Zhang JianHui
[chemotherapy]
[Treatment Effectiveness and Hematologic Adverse Effects of Ribociclib]
The patient has a history of invasive carcinoma of no special type (NST) initially diagnosed via a breast biopsy on 2022-05-17, followed by a right simple mastectomy on 2022-06-27, confirming Grade 1 invasive carcinoma and ductal carcinoma in situ (DCIS) with negative resection margins and no lymphovascular or perineural invasion. AJCC 8th edition stage was determined as pT1cN0, anatomic stage IA, indicating early-stage disease. Hormonal receptor positivity (ER 100%, PR 1%) and HER2 negativity (score 1+) suggest a luminal A-like phenotype (2024-02-16).
Following surgery, the patient underwent adjuvant hormone therapy with Femara (letrozole), maintained regularly from 2022-06-06 until 2024Q4. Progressive lymph node involvement was noted in 2024-02-27 with metastatic invasive carcinoma identified in 2/4 right axillary lymph nodes. This prompted systemic chemotherapy with cyclophosphamide and liposomal doxorubicin (AC(lipo)) initiated on 2024-03-06, followed by docetaxel cycles from 2024-06-03 to 2024-08-05.
Ribociclib (Kisqali) was introduced on 2024-09-13 as part of a combination regimen for metastatic disease control alongside ongoing letrozole. Imaging on 2024-09-06 indicated reduced glucose hypermetabolic activity in previously noted areas, including the mediastinal LAPs and right axillary region, suggesting treatment effectiveness. No evidence of distant metastatic disease was noted on follow-ups (2024-09-13 MRI brain, 2024-11-25 abdominal ultrasound).
[Comments on Neutropenia]
[Addressing Hematologic Adverse Effects of Ribociclib]
Lab data
2024-11-01 WBC 1.37 x10^3/uL
2024-10-07 WBC 1.17 x10^3/uL
2024-09-23 WBC 2.94 x10^3/uL
2024-09-13 WBC 5.81 x10^3/uL
2024-08-05 WBC 5.46 x10^3/uL
2024-07-15 WBC 5.55 x10^3/uL
2024-06-24 WBC 5.93 x10^3/uL
2024-06-12 WBC 1.03 x10^3/uL
2024-06-03 WBC 2.19 x10^3/uL
2024-05-10 WBC 2.87 x10^3/uL
2024-04-18 WBC 3.34 x10^3/uL
2024-03-27 WBC 2.72 x10^3/uL
2024-03-13 WBC 5.30 x10^3/uL
2024-02-26 WBC 4.34 x10^3/uL
2024-11-01 Neutrophil 74.3 %
2024-10-07 Neutrophil 58.6 %
2024-09-23 Neutrophil 74.5 %
2024-09-13 Neutrophil 57.1 %
2024-08-05 Neutrophil 56.9 %
2024-07-15 Neutrophil 84.5 %
2024-06-24 Neutrophil 71.6 %
2024-06-12 Neutrophil 26.8 %
2024-06-03 Neutrophil 51.6 %
2024-05-10 Neutrophil 65.9 %
2024-04-18 Neutrophil 63.4 %
2024-03-27 Neutrophil 59.9 %
2024-03-13 Neutrophil 66.6 %
2024-02-26 Neutrophil 65.6 %
Case Context
Recommendations
This patient’s neutropenia appears treatment-related and is manageable with dose adjustments, potential G-CSF support, and close monitoring. Balancing effective cancer therapy with minimizing adverse effects is crucial in older, comorbid patients, as emphasized by the NCCN guidelines. The suggested adjustments aim to maintain efficacy while reducing the risk of severe hematologic complications.
[exam finding]
[surgical operation]
[Patient Summary]
This is a 43-year-old male with a history of hypertension under medical control and a prior excision of a thigh mass (2024-04-02, lipomatous and panniculitis change), presenting with intractable back pain and bilateral lower limb weakness and numbness over the past two weeks. MRI of the thoracic spine (2024-12-22) revealed abnormal marrow changes in the T10 and T11 vertebrae with an epidural tumor invasion, highly suspicious for metastatic lesions. Pathological confirmation (2024-12-25) identified the lesion as diffuse large B-cell lymphoma (DLBCL), GCB subtype.
Additionally, he underwent T10-11 laminectomy and T11 kypho-vertebroplasty (2024-12-24) with findings of significant spinal cord compression by an epidural tumor. Neurological deficits and mechanical back pain remain significant clinical issues. Laboratory findings, imaging, and histopathology collectively suggest a systemic lymphoma involving the spine, with no prior documented malignancy history.
[Problem Comments]
Problem #1: T11 Pathologic Fracture with Epidural Spinal Cord Compression
Problem #2: L-Spine Degenerative Changes and Mechanical Instability
Problem #3: Systemic Evaluation and Tumor Staging
Final Plan Summary:
[lab data]
2024-11-21 HLA A-high 02:06
2024-11-21 HLA A-high 02:07
2024-11-21 HLA B-high 46:01
2024-11-21 HLA B-high 55:02
2024-11-21 HLA C-high 01:02
2024-11-21 HLA C-high 03:03
2024-11-21 HLA DQ-high 03:03
2024-11-21 HLA DQ-high -
2024-11-21 HLA DR-high 09:01
2024-11-21 HLA DR-high -
2024-10-16 JAK2 gene mutation quan 0.00 %
2024-10-16 FLT3-D835 (BM) Undetectable
2024-10-16 P.jiroveci DNA-Sp Undetectable
2024-10-09 FLT3/ITD (BM) Presence of mutation
2024-10-09 NPM1 (qual) (BM) Undetectable
2024-10-04 HBsAg Reactive
2024-10-04 HBsAg Value 4628.62 S/CO
2024-10-04 Anti-HBc Reactive
2024-10-04 Anti-HBc Value 9.07 S/CO
2024-10-04 Anti-HCV Nonreactive
2024-10-04 Anti-HCV Value 0.21 S/CO
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
Acute Myeloid Leukemia (AML) with FLT3/ITD Mutation
Infection-Related Complications
Defer live vaccines until the patient has completed chemotherapy and demonstrated immune recovery (WBC ≥3.0 × 10³/μL, ANC ≥1.5 × 10³/μL).
Pneumococcal vaccines can be scheduled during immune recovery phases or after chemotherapy, as they are critical for preventing severe pneumococcal disease in this high-risk patient.
Hematologic Findings and Supportive Care
Cardiopulmonary Concerns
Chronic Conditions: COPD
Nutrition and Metabolic Status
[exam findings]
[MedRec]
[Surgical operation]
[chemotherapy]
GRAALL-2003 regimen - 2024-12-26 - Perplexity
The GRAALL-2003 regimen is a pediatric-inspired treatment protocol for adults with Philadelphia chromosome-negative acute lymphoblastic leukemia (ALL). This regimen was designed for patients aged 15 to 60 years and showed improved outcomes compared to previous adult ALL protocols3.
Induction
Consolidation - Consists of 9 alternating blocks:
Late Intensification - Administered between consolidation blocks 6 and 7, with different regimens for patients in complete remission (CR) after first induction or salvage course1.
Maintenance Therapy
CNS Prophylaxis
Citations:
This 18-year-old male patient has T-cell acute lymphoblastic leukemia (T-ALL) initially diagnosed on 2024-04-22. He is undergoing treatment per the GRAALL-2003 regimen, currently in Block 9 of consolidation chemotherapy. Historical bone marrow examinations indicate periods of remission (2024-06-07, 2024-09-01) followed by residual disease recurrence (2024-11-11). His current hospitalization included chemotherapy from 2024-12-24 to 2024-12-25, and a bone marrow evaluation is pending as of 2024-12-26. His clinical condition is stable, and he will be discharged on Lenograstim for home management, with outpatient follow-up arranged.
Problem 1: Acute Lymphoblastic Leukemia (T-ALL) with Residual Disease
Problem 2: Risk of Treatment-Related Toxicities
Problem 3: Long-Term Management of T-ALL
[Neutropenia: Determining Cause and Treatment Options]
The patient has developed neutropenia recently. While the Oncoginase package insert doesn’t emphasize neutropenia as an important side effect, the medications administered on 2024-05-20 - daunorubicin, vincristine, and cyclophosphamide - are known to be more likey to cause neutropenia.
If a further decrease in WBC count is anticipated, the use of G-CSF could be considered as a proper measure.
[Key Summary]
Primary Concerns: The patient, a 66-year-old male, presents with normocytic anemia, generalized lymphadenopathy, and a suspected lymphoma (evidence: MRI pelvis on 2020-11-06, CT abdomen/pelvis on 2024-11-14).
Comorbidities: Coronary artery disease, severe aortic stenosis, chronic kidney disease (stage III), paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic nephropathy, and old cerebrovascular accident with left hemiplegia.
Notable Labs:
Physical Exam: A 3 cm nodule in the left neck, hyperpigmented skin, and generalized lymphadenopathy.
Medications: Includes antihypertensives, antiplatelets, anticoagulants, and diabetic medications.
[Problem-Oriented Comments]
Problem 1: Normocytic Anemia
Problem 2: Generalized Lymphadenopathy
Problem 3: Chronic Kidney Disease (Stage III)
[Medication Review]
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
[Key Summary]
The patient is a 72-year-old male with stage IIIa adenocarcinoma of the sigmoid colon (cTxN1M0), undergoing Total Neoadjuvant Therapy (TNT) with concurrent chemoradiation (CCRT) and FOLFOX. He was admitted with febrile neutropenia and hypokalemia. Abdominal imaging reveals significant gastrointestinal findings, including ileus and bowel wall edema. Laboratory data confirms neutropenia with an absolute neutrophil count (ANC) of 172 (2024-12-25) and hypokalemia (K+ 2.8 mmol/L).
[Problem-Oriented Comments]
Problem 1: Neutropenia with Fever
Problem 2: Hypokalemia
Problem 3: Bowel Symptoms (Diarrhea and Ileus)
[Medication Review]
[exam finding] (not completed)
[MedRec]
[immunochemotherapy]
{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
certain medication
[stable PSA levels under docetaxel and goserelin regimen, prophylactic G-CSF proves effective in preventing neutropenia, considering denosumab reintroduction for spine metastasis findings]
Under the current docetaxel and goserelin regimen, the patient’s PSA levels have remained stable at around 70 ng/mL, consistent with the past few months, indicating the disease is still under control.
Since 2021-11, Granocyte (lenograstim) has been administered for three consecutive days, starting approximately one week after almost each docetaxel treatment. Recent data shows very few instances of neutropenia, suggesting the prophylactic use of G-CSF has been effective.
Apart from anemia, lab results are generally normal, and no medication issues have been identified.
Xgeva (denosumab) was used between 2022-08 and 2023-10, but a follow-up MRI on 2024-07-06 showed retrolisthesis of L2 on L3 (grade I), multiple ill-defined mass lesions over the lumbar and sacral spine consistent with metastases, and spondylolisthesis of L4 on L5 (grade I). Given these findings, it is recommended to evaluate whether to resume Xgeva based on the patient’s overall clinical condition.
[stable PSA and disease control with ongoing disease control with docetaxel and goserelin]
PSA levels have remained stable at around 70 ng/mL over the past three months. A July CT scan, compared with the previous quarter, indicates that the disease has remained stable, suggesting that the current docetaxel and goserelin regimen is still effective.
Other lab results from 2024-08-19 were generally normal, and no medication discrepancies were identified.
[stable PSA levels post-docetaxel therapy; managing HBV reactivation and neutropenia effectively]
Since initiating docetaxel treatment on 2023-09-28 after a six-month interval, there appears to be no trend of PSA doubling as of late December 2023, suggesting a stable response to the therapy.
Lab tests on 2024-04-10 were largely normal. The patient continues to take Baraclude (entecavir) and Granocyte (lenograstim) is used as a preventive measure against HBV reactivation and neutropenia, similar to previous protocols, with no discrepancies in medication identified.
2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.
All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.
assessment
suggestion
assessment
suggestion
[exam finding] (not completed)
2024-12-16 CT - abdomen
2024-11-11 Ascites tapping
2024-11-05 PTCD (percutaneous transhepatic cholangial drainage) revision
2023-11-01 Patho - liver biopsy needle/wedge
2024-10-30 ECG
2024-09-25 CT - abdomen
2024-04-29 CT - abdomen
2024-01-24 CT - abdomen
….-..-..
2023-09-25 Patho - breast simple/partial mastectomy
2023-08-21 Patho - breast biopsy (no need margin)
2022-08-02 Patho - colon biopsy
[MedRec]
[chemotherapy]
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
Patient Summary
Problem-Oriented Comments
Active Medication Review
[Assessing Thyroid Status and Treatment Needs]
This patient is taking self-carried Thyroid-S (T4 0.1mg) 1# QDAC.
The recent 3-month prescriptions in PharmaCloud do not include any thyroid-related medication such as levothyroxine (used for hypothyroidism) or antithyroid drugs (used for hyperthyroidism). There is also no lab data (e.g., TSH, FT4) to support hyperthyroidism.
Assessment and Next Steps:
[exam findings]
[MedRec]
[Key Summary]
This 75-year-old male has the following significant medical issues:
[Problem-Oriented Comments]
Follicular Lymphoma Staging and Management
Cognitive Decline
Chronic Conditions Management
[Active Medication Review]
Potential Issues:
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Fluconazole Therapy for Candidemia in the Patient with Renal Impairment]
Patient Summary
This is a 60-year-old male with a history of:
Lab and Exam Evidence of Candida Infection
Diagnosis
Fluconazole Treatment
Loading Dose (Day 1)
Maintenance Dose (Day 2 Onwards)
Treatment Duration
Monitoring
Rationale
Contingency Plan
[Oral fluconazole administraion]
Patient Summary
Oral fluconazole considerations
Administration Plan
Rationale
Oncological Concerns
Renal Function and Nephrological Management
Hematological and Systemic Health
Infection and Inflammation
Nutrition and Supportive Care
Current Active Medications
[Medication Review]
[Analysis of Culture and Antibiogram]
Microorganisms Identified:
Recommendations for Antibiotic Therapy:
Monitoring and Follow-Up:
[lab data]
2024-08-09 Anti-HBc Nonreactive
2024-08-09 Anti-HBc Value 0.12 S/CO
2024-08-09 HBsAg Nonreactive
2024-08-09 HBsAg Value 0.74 S/CO
2024-08-09 Anti-HCV Nonreactive
2024-08-09 Anti-HCV Value 0.15 S/CO
2024-07-26 CA125 251.2 U/mL
2024-06-27 CA-125 (NM) 190.110 U/ml
2024-06-21 D-dimer 3206.00 ng/mL (FEU)
2023-10-25 ANA Centromere 1:1280
2023-10-23 Anti ENA (Ro,La) 2023-10-23 Anti-ENA SS-A (Ro) 24 EliA
U/ml
2023-10-23 Anti-ENA SS-B (La) <0.3 EliA U/ml
2023-10-23 ANCA 2023-10-23 PR3 Negative IU/ml
2023-10-23 PR3 Value <0.6 IU/ml
2023-10-23 MPO Negative
2023-10-23 MPO Value 2.5 IU/ml
2021-09-13 ANA Centromere; Cytoplasmic; 1:640
2021-05-24 ANA Centromere; Cytoplasmic; 1:640
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Neutropenia Post-Chemotherapy
Chronic DVT Secondary to May-Thurner Syndrome
Cachexia and Anorexia in Metastatic Cancer
Active Medication Review
[taxol and carboplatin treatment cleared by lab results]
The patient is scheduled for treatment with Taxol and Carboplatin. Based on the blood cell count, electrolytes, liver, and renal function lab results from 2024-08-14, there is no evidence of contraindications.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Findings
Recommendations
[adjusting carboplatin and etoposide dosing for renal impairment]
The patient’s kidney function is trending downward.
With an eGFR of 37, if carboplatin is to be used, it is recommended to administer 75% of the usual dose for patients with a CrCl of 15 to 50 mL/minute.
For carboplatin AUC dosing using the Calvert formula, with the following patient details - age 79 years, weight 48.5 kg, creatinine 1.43 mg/dL, target AUC 4 mg/mL/min, and female gender - the calculated total dose is 197.7 mg.
Carboplatin AUC Dosing (Calvert) Calculator - 2024-08-20 - https://reference.medscape.com/calculator/169/carboplatin-auc-dosing-calvert
[tube feeding: options for administering Adapine and Const-K]
The half-life elimination of nifedipine varies among different populations: in healthy adults, it ranges from 2 to 5 hours; in individuals with cirrhosis, it extends to 7 hours; and in the elderly, it also reaches about 7 hours when using extended-release tablets.
Adapine S.R.F.C. (sustained-release film-coated) tablets are designed not to break down within the body, hence it is common to find the intact outer shell in the patient’s feces. The design of these tablets is meant to maintain steady drug levels in the bloodstream. Crushing these tablets will compromise their slow-release properties, making them ineffective at sustaining intended drug concentrations. If there is a need to continue using this medication, it should ideally be administered in divided doses to maintain stable blood levels.
Const-K 750mg is an extended-release tablet that delivers 10 mEq of potassium per tablet and is the only oral potassium supplement available in this hospital. If injectable potassium supplementation is not preferred, Const-K tablets can be crushed into fine particles for easier administration with water.
[evaluating the possibility of fungal infection in unresolved lung consolidation]
Neutropenia has largely resolved, yet CRP levels remain elevated while PCT has returned to normal ranges. Based on the comparison of CXR images from 2024-07-15 and 2024-07-05, patchy consolidation in the lower left lobe of the lung showed no improvement. If respiratory symptoms do not improve, a fungal infection could be suspected.
2024-07-17 WBC 3.41 x10^3/uL
2024-07-16 WBC 3.37 x10^3/uL
2024-07-15 WBC 0.61 x10^3/uL
2024-07-11 WBC 0.24 x10^3/uL
2024-07-08 WBC 0.26 x10^3/uL
2024-07-05 WBC 11.74 x10^3/uL
2024-07-01 WBC 3.41 x10^3/uL
2024-07-16 CRP 15.8 mg/dL
2024-07-15 CRP 15.3 mg/dL
2024-07-11 CRP 23.4 mg/dL
2024-07-08 CRP 14.3 mg/dL
2024-07-05 CRP 34.2 mg/dL
2024-07-16 Procalcitonin (PCT) 0.32 ng/mL
2024-07-15 Procalcitonin (PCT) 0.42 ng/mL
2024-07-11 Procalcitonin (PCT) 1.89 ng/mL
2024-07-08 Procalcitonin (PCT) 11.44 ng/mL
2024-07-05 Procalcitonin (PCT) 13.06 ng/mL
[carboplatin and etoposide administration and subsequent neutropenia]
Carboplatin and etoposide were administered on 2024-07-02, and neutropenia was noted on 2024-07-08. Given the elevated CRP and PCT levels, infection cannot be ruled out. Consequently, a 3-day course of Granocyte (lenograstim) was initiated on 2024-07-08. Blood transfusions were also conducted on 2024-07-01, 2024-07-05, and 2024-07-09. These measures are considered appropriate for the condition.
2024-07-08 Procalcitonin (PCT) 11.44 ng/mL
2024-07-05 Procalcitonin (PCT) 13.06 ng/mL
2024-07-08 CRP 14.3 mg/dL
2024-07-05 CRP 34.2 mg/dL
2024-07-08 WBC 0.26 x10^3/uL *
2024-07-05 WBC 11.74 x10^3/uL
2024-07-01 WBC 3.41 x10^3/uL
2024-06-30 WBC 3.76 x10^3/uL
2024-06-18 WBC 5.77 x10^3/uL
2024-06-17 WBC 5.93 x10^3/uL
2024-07-08 HGB 8.9 g/dL
2024-07-05 HGB 8.0 g/dL
2024-07-01 HGB 8.2 g/dL
2024-06-30 HGB 8.7 g/dL
2024-06-18 HGB 9.6 g/dL
2024-07-08 PLT 103 *10^3/uL
2024-07-05 PLT 227 *10^3/uL
2024-07-01 PLT 271 *10^3/uL
2024-06-30 PLT 253 *10^3/uL
2024-06-18 PLT 326 *10^3/uL
[exam finding]
[MedRec]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[thalassemia management and stable lab results, transition from ac to docetaxel treatment: neutropenia monitoring advised]
After four AC regimen treatments on 2024-07-01, 2024-07-20, 2024-08-10, and 2024-08-27, leukopenia events were frequently observed about one week after each session. The AC treatment cycle has now been completed, and the patient has begun treatment with docetaxel. It is recommended to continue monitoring for neutropenia.
The patient has a comorbidity of thalassemia, which manifests as anemia. Foliromin (ferrous sodium citrate 50mg) 1# BID has been prescribed for management. Electrolytes are balanced, and liver and kidney functions remain stable, with no need for dosage adjustments based on current conditions. No medication issues have been identified.
2024-09-13 HGB 8.5 g/dL
2024-09-13 WBC 7.90 x10^3/uL
2024-09-06 WBC 0.59 x10^3/uL ***
2024-08-27 WBC 8.20 x10^3/uL
2024-08-26 WBC 2.30 x10^3/uL *
2024-08-25 WBC 1.17 x10^3/uL **
2024-08-16 WBC 2.23 x10^3/uL *
2024-08-10 WBC 4.15 x10^3/uL
2024-07-26 WBC 3.71 x10^3/uL
2024-07-20 WBC 3.26 x10^3/uL
2024-07-08 WBC 2.90 x10^3/uL *
2024-06-29 WBC 11.48 x10^3/uL
[exam findings]
[consultation]
[chemotherapy]
2024-12-10 - NS 50mL 15min + OBI-992 4mg/kg 336mg NS 216.4mL 3hr + NS 30mL 5min + NS 200mL 30min (OBI-992: anti-TROP2 ADC)
2024-10-30 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-10-16 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-09-25 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-09-11 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-08-28 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-08-14 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-07-31 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-07-17 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-07-03 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-06-19 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-06-04 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + cisplatin 25mg/m2 45mg NS 500mL 24hr (Y-sited Covorin 5-FU) + leucovorin 120mg/m2 230mg NS 250mL 24hr (Y-sited Kemoplat 5-FU) + fluorouracil 2200mg/m2 4200mg NS 500mL 24hr (Y-sited Covorin Kemoplat) (EEPFL)
….-..-..
2022-11-08 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
2022-10-25 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
2022-09-28 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
2022-09-13 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
2022-08-29 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
GOLF regimen ref:
[Key Summary]
The patient is a 58-year-old male with advanced duodenal adenocarcinoma (cT4N2M1, Stage IV) complicated by:
Laboratory data:
[Problem Review]
Objective
Assessment
Recommendations
[Medication Review]
Key Medications
Appropriateness Review
The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.
The decreased CA199 marker also served as a side evidence that the regimen is still effective.
Data available indicate stable vital signs, and there is no problem with the active prescription.
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Evaluation of Anemia]
Current Status of Anemia (2024-12-10):
Relevant Historical and Clinical Context:
Possible Contributing Factors to Anemia:
Recent Trends:
Risk Assessment:
Recommendations:
Further Tests:
[Evaluation of Treatment Effectiveness]
Primary Disease (Hodgkin Lymphoma):
Systemic and Nutritional Health:
Recommendations
Current Findings and Management Needs:
[advanced Hodgkin lymphoma: treatment strategies and options]
The NCCN guidelines (20241022) provide several recommendations for advanced-stage Hodgkin lymphoma (Stage III-IV), highlighting some options that might be appropriate for this patient:
Given the patient’s advanced age and current comorbidities, selecting a regimen that balances efficacy and manageable toxicity, such as Brentuximab + AVD or Nivolumab + AVD, could be suitable.
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[consultation]
[Key Summary]
[Problem List]
[Medication Review]
Hydralazine HCl (Brand: Apolin) 25 mg PRN Q6H (for BP control)
Denosumab (for bone metastases)
Gemcitabine + Cisplatin (Chemotherapy for cholangiocarcinoma/metastatic disease)
Nebivolol 5 mg QD (for hypertension)
Metformin 500 mg BID (for diabetes)
Oxybutynin ER 5 mg QD (for overactive bladder)
Tramadol/Acetaminophen 37.5/325 mg PRN Q6H (for pain)
Folacin (Folic Acid) 5 mg QD
Exforge (Amlodipine/Valsartan) 5 mg/160 mg QD (for hypertension)
[exam finding]
2024-11-01 KUB
2024-10-29 Upper GI & Small Intestine
2024-10-26 LUB
2024-10-26 CXR
2024-10-16 CXR
2024-10-14 SONO - chest
2024-10-12 CT - abdomen
2024-09-10 KUB
2024-08-12 KUB
2024-07-12 Ascites tapping
2024-06-13 CXR
2024-06-13 Pure Tone Audiometry, PTA
2024-06-12 CXR
2024-06-12 ECG
2024-05-31 Ascites tapping
2024-04-01 Patho - peritoneum biopsy
2024-03-29 ECG
2024-03-19 Whole body PET scan
2024-02-06 Ascites tapping
2024-01-25 ECG
2024-01-25 Ascites tapping
2024-01-25 SONO - abdomen
2024-01-22 CT - abdomen
2024-01-17 SONO - gynecology
2024-01-12 SONO - abdomen
2023-06-08 Ascites tapping
2023-06-08 SONO - abdomen
2023-05-15 PET
2023-05-05 SONO - gynecology
2023-04-27 Patho - omentum biopsy
2023-04-27 Patho - peritoneum biopsy
2023-04-25 ECG
2023-04-25 Colonoscopy
2023-04-24 SONO - gynecology
2023-04-22 Ascites tapping
2023-04-22 SONO - abdomen
2023-04-21 CT - abdomen
2023-02-03 SONO - abdomen
2023-01-16 SONO - breast
2022-12-30 CT - abdomen, pelvis
[MedRec]
[consultation]
[immunochemotherapy]
Key Findings:
Management Recommendations:
The patient is a 37-year-old female with advanced right lower lung cancer (adenosquamous carcinoma, Stage IVb) with metastases to the skull, pleura, left lung, spine, and multiple bones.
[Intervention Review]
The patient has extensive bone metastases and a history of compression fractures treated with vertebroplasty and laminectomy.
Current Status:
Recommendation:
The patient has Grade 2 anemia (HGB: 8.3 g/dL), likely due to chemotherapy and chronic disease.
Current Status:
Recommendation:
The patient has recurrent malignant effusion and bilateral pneumonitis.
Current Status:
Recommendation:
Medication Review
[tube feeding]
All the oral medications on the active list are suitable for tube feeding.
Nutritional Support
Monitoring Fluid and Electrolyte Balance
Tube feeding can predispose patients to dehydration or electrolyte imbalances, especially in patients with concurrent chemotherapy and high-output losses (e.g., from malignant pleural effusion).
Current Status:
Recommendations:
Risk of Aspiration
Aspiration is a serious concern in tube-fed patients, especially with pleural effusion and bilateral pneumonitis.
Recommendations:
Complications of Tube Feeding
Specific Adjustments for the Patient
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2024-12-20 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr
2024-12-04 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr
2024-11-15 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr
2024-10-25 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr
2024-10-11 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr
2024-09-03 - bevacizumab 5mg/kg 200mg NS 140mL 90min + oxaliplatin 50mg/m2 65mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
2024-08-19 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr
[Patient Summary]
The patient, a 67-year-old female, has a history of advanced rectosigmoid junction adenocarcinoma (pT4aN1bM1c, Stage IV), with documented peritoneal carcinomatosis and metastases to the lungs, liver, and spleen. She has undergone multiple surgical interventions, including a colostomy (2023-07-27), and has experienced complications such as rectovaginal fistula, ascites, ileocolostomy herniation, and small bowel obstruction (KUB findings on 2025-01-10). Her chemotherapy has included regimens like XELOX (capecitabine and oxaliplatin) and FOLFOX, with intervals of stable disease, tumor regression (CT findings on 2024-11-19), and tolerable side effects. However, complications such as infection, gastrointestinal symptoms, and poor nutritional status have necessitated hospitalizations.
[Problem Comments]
Problem 1: Metastatic Rectosigmoid Junction Adenocarcinoma
Problem 2: Small Bowel Obstruction
Problem 3: Nutritional Deficiency and Cachexia
Problem 4: Rectovaginal Fistula
Problem 5: Hyponatremia
Problem #1: Adenocarcinoma of the Rectosigmoid Junction with Peritoneal Carcinomatosis and Metastases
Problem #2: Recto-Vaginal Fistula
Problem #3: Cachexia and Poor Nutrition
Problem #4: Hyponatremia
Problem #5: Chemotherapy-Associated Anemia
Problem #6: Pain Management
[fluconazole dosing strategy for candida albicans in low-weight patient]
Sputum culture results identified Klebsiella pneumoniae and Candida albicans. The former has been treated with Tapimycin (piperacillin/tazobactam), to which the Klebsiella is sensitive, and fluconazole was prescribed this evening for the Candida infection.
Directed Therapy (Candida albicans identified): Fluconazole is recommended at a loading dose of 800 mg (12 mg/kg), followed by 400 mg IV/PO daily once blood cultures have cleared and the patient is clinically stable.
The patient weighs 46.5 kg, which approximates a loading dose of 558 mg (equivalent to 3 to 4 capsules of 150 mg each), followed by a maintenance dose of 2 capsules (300 mg) daily.
[exam findings]
2024-12-01, -11-11 CXR
2024-11-21 CT - chest
2024-11-08 Patho - bronchus biopsy
2024-11-08 Bronchoscopy
2024-11-05 Upper GI Series
2024-11-02 CT - chest
2024-11-02 Esophagogastroduodenoscopy, EGD
2024-10-07 CXR
2024-09-18 SONO - abdomen
2024-08-21 CT - chest
2024-08-07 CXR
2024-06-26 SONO - abdomen
2024-05-20, -05-19, -05-05 CXR
2024-05-09 Bronchoscopy
2024-05-09 Miniprobe Endoscopic Ultrasound
2024-05-08 Tc-99m MDP bone scan
2024-05-07 PET
2024-05-06 MRI - brain
2024-05-06
2024-05-06 2D transthoracic echocardiography
2024-04-24 Bladder Sonography
2024-04-24 Uroflowmetry
2024-04-23 Microsonography
2024-04-12 CT - chest
2024-04-10 Patho - esophageal biopsy
2024-04-03 SONO - abdomen
2024-03-27 Microsonography
2024-01-10 SONO - abdomen
2023-10-26 MRI - prostate
2023-10-23 CT - abdomen
2023-10-18 SONO - abdomen
2023-10-16 Tc-99m MDP bone scan
2023-10-03 Patho - prostate needle biopsy
2023-10-03 Patho - prostate needle biopsy
2023-07-26 SONO - abdomen
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Clinical Conditions
Key Concerns and Recommendations
[Anemia]
Laboratory Evidence of Anemia - Recent hematological parameters reveal significant anemia:
Likely Etiologies
Diagnostic and Clinical Correlations
Management Recommendations
Patient Overview - This 68-year-old male patient has a complex medical history, including:
Recent Clinical Findings
Anemia and Blood Findings - This patient exhibits chronic anemia characterized by:
Anemia Analysis and Recommendations
Comorbid Conditions and Management Considerations
Medications Review for Nephrotoxicity, Hepatic Considerations, and Interactions (below not posted)
[persistent anemia and multiple transfusions]
The patient’s hemoglobin (HGB) levels have remained below the reference range throughout the year.
Blood transfusions were administered on 2024-05-19, 2024-07-02, 2024-07-06, 2024-07-12, 2024-07-18, 2024-07-25, 2024-07-29, 2024-09-05, and 2024-10-07.
If future transfusions are not viable, it may be necessary to consider alternative treatment options.
[correcting hyponatremia, hypomagnesemia: adding albumin support]
Hyponatremia, hypomagnesemia, and hypoalbuminemia have been observed in the patient.
MgSO4 and normal saline are currently being administered.
Considering the low albumin levels, albumin supplementation or more intensive nutritional support may be appropriate to address the deficiencies.
[blood transfusion for anemia with mild lab abnormalities]
Anemia was noted on 2024-09-05, with HGB at 8.4 g/dL, prompting an LPRBC transfusion on the same day. Other lab results revealed mild hyponatremia, hypoalbuminemia, and a slightly elevated bilirubin level. No medication reconciliation issues were identified.
[anemia progression despite blood transfusion]
This patient has been receiving the PF regimen since 2024-05-29, and has since experienced a significant decline in HGB, reaching grade 3 (severe) anemia by July. The PF regimen, which includes cisplatin and fluorouracil, is associated with anemia incidences of up to 40% for cisplatin and unspecified rates for fluorouracil.
Although the sharp decline in HGB occurred after chemotherapy, suggesting a possible causal relationship, the patient’s HGB levels had already started decreasing before starting the PF regimen. Given that the latest PF regimen administration was at least a month ago, HGB levels would typically be expected to recover; however, the patient’s HGB has been continuously decreasing.
The patient received a blood transfusion on 2024-07-02 (the same day as the 2nd session of chemotherapy). Despite the transfusion, HGB levels have continued to fall. If the patient cannot regain hematopoietic ability or tolerate frequent transfusions (if needed), it may be necessary to further reduce the dosage or change the regimen.
[deteriorating liver function and treatment options]
The patient’s liver function is deteriorating, and BaoGan (silymarin) is currently being used. Given that BDI is increasing and is the main contributor to elevated BTI, adding Uliden (ursodeoxycholic acid) might be beneficial if clinically appropriate.
2024-07-02 ALT 90 U/L
2024-06-24 ALT 21 U/L
2024-07-02 AST 113 U/L
2024-06-24 AST 24 U/L
2024-07-02 Bilirubin direct 0.35 mg/dL
2024-06-03 Bilirubin direct 0.24 mg/dL
2024-05-29 Bilirubin direct 0.21 mg/dL
[exam findings]
[MedRec]
[chemotherapy]
UFT (tegafur 100mg, uracil 224 mg)
[Simple Suspension Method (SSM) for Medication Tube Feeding]
SSM is a technique used to administer medications to patients who are unable to swallow, such as those receiving enteral tube feeding. It involves suspending medications in warm water to dissolve or disperse them, allowing for easier administration through a feeding tube.
Steps Involved in SSM:
Advantages of SSM:
Considerations:
[tube feeding - UFT handling precautions]
UFT (tegafur and uracil) is cytotoxic, posing a potential health hazard if directly contacted. Therefore, it is strongly recommended that healthcare personnel follow strict safety protocols when handling UFT granules to prevent exposure.
[exam finding]
[MedRec]
[consultation]
[Key Clinical Findings and Current Status]
[Current Lab Evidence]
[Management Recommendations]
Oncologic Management
Renal Support
Diabetes Management
Nutritional Optimization
Symptom Management
Palliative and Supportive Care
Key Clinical Findings and Current Status
Would you like a more detailed treatment timeline or further clarification?
[MedRec]
[consultation]
Haloperidol 5mg 0.5amp PRNQ6H IM if agitated
Titrate Utapine according to response, maximum 150mg/day
Delirium recovery behavioral modification
If the patient is bedridden during the day, elevate the head of the bed to a sitting position to prevent drowsiness.
Encourage wheelchair mobility and active rehabilitation for most of the day.
Provide orientation information regularly: remind the patient of the date, location, and surrounding people and things.
Maintain a day-night cycle by using natural light from windows and artificial light from lamps.
Arrange PSY OPD follow-up after discharge
As long as reposition the patient regularly, her wound won’t open up any further.
Please continue to change her wet dressing daily. Be careful not to stuff the gauze into the wound, as this could cause it to open wider.
We will not remove the stitches for now. Leaving the stitches in for more than a month will not cause infection and can actually prevent the wound from reopening.
Please call us before she is discharged or if her wound worsens.
[MedRec]